Nuffield Health Warwickshire Hospital

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

There was a positive learning culture with staff managing incidents well. Learning from incidents was evident. Staff knew what incidents required reporting and how to report them. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service-controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. There were processes in place to ensure the service mostly had enough staff with the right training, skills and qualifications to keep patients safe from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

All staff knew what incidents to report and how to report them via the online reporting system. Staff raised concerns and were encouraged to report incidents by their managers. Staff told us that changes had been made because of feedback. For example, the wrong patient was brought down to theatre, so the service implemented a new process to ensure they had the right patient including a new checklist and patient collection slip. The service had no ‘never events’ in the last 12 months. We were told about an incident where a patient had a post-operative bleed and staff felt worried by this. The manager had since arranged training at the team meeting and was doing drop-in teaching sessions for staff. There was a positive culture for incident reporting and learning and staff were able to give examples of changes made within the theatres following incidents. Managers investigated all incidents thoroughly and implemented changes where needed. Managers shared feedback from incidents with staff and learning was used to improve the service.

The service had clear policies for incident management. They explained how to report, categorise, and investigate incidents. Incidents were discussed within governance meetings and team meetings. Where learning was required, there were processes to follow for staff to ensure this was shared and embedded. Managers used several methods to share learning with staff including a secure online messaging and collaboration application and team meetings. Staff gave examples of changes implemented following incidents to improve patient care. There were measures in place to keep patients safe. For example, where theatre lists were changed on the day of surgery, they were printed on a different colour paper and distributed to the theatre and ward staff to ensure everyone was aware of the changes. There were shared learning across the Nuffield Health group and they learned from other serious incidents that happened in other hospitals. We saw information about these were displayed including actions for staff. Staff were aware of the duty of candour and managers had used it where serious incidents had occurred. There was an ‘Outcomes with Learning’ (OWL) where incidents were discussed, and practices were changed. We saw an OWL displayed on the noticeboard with clear actions for staff.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff knew how to make a safeguarding referral and who to inform if they had concerns. The service had safeguarding processes and procedures in place. At the time of our inspection 88% of staff were trained to level 2 safeguarding adults and 95% were trained to level 2 safeguarding children and 89% of staff were trained to safeguarding adults level 3; this was just below the training target of 90%. The safeguarding lead for the service locally was the director of clinical services who worked on site; they were trained to level 3. All preassessment staff were trained to level 3. Staff could give examples of how to protect patients at risk of, or suffering, significant harm. Staff understood the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) and had completed training on these. Staff told us they occasionally had patients who lacked capacity. The ward sister had received enhanced dementia training. Staff attended dementia training and knew how to care for patients living with dementia.

The hospital had a clear safeguarding policy and pathway which was up-to-date and accessible to staff through the intranet. Safeguarding posters were displayed in pre-operative assessment, theatres and in ward areas and staff knew where to find the safeguarding policies and procedures. Staff all knew who the safeguarding lead was for advice.

Staff made sure patients and those close to them understood their care and treatment. Patients received support to manage risk. A patient gave us an example of how staff provided specific information in relation to their mobility following surgery. We observed an alarm call out during our assessment. All staff stopped what they were doing and attended to a patient who had experienced a vasovagal. This was effectively managed, the patient was taken to their room and reviewed by the resident medical officer.

Staff used a nationally recognised tool to identify deteriorating patients and escalated them appropriately. The National Early Warning Score (NEWS2) was used for adults. Any patients with a NEWS2 of 4 or more would trigger a review from the doctor. During our review of the NEWS2 charts, we found these were calculated and escalated correctly. The service used the ‘5 steps to safer surgery’, World Health Organisation (WHO) surgical safety checklist, in line with National Patient Safety Agency guidelines. We looked at 5 sets of notes on the ward and these were all completed. Staff had the relevant life support training for their role. There was 1 recovery nurse who was trained to advanced life support (ALS) and 9 ward staff trained in ALS. The clinical lead for anaesthetics and recovery was hoping more recovery nurses would complete their ALS training. Staff told us they completed their mandatory training online. At the time of the assessment, training compliance for immediate life support (ILS) was 54%. Following our assessment, data provided to us showed 90% of ward staff had received ILS training. Staff and their managers were sent reminders when training was overdue. One staff told us; “there are good optional extra courses available”. In theatre, before the anaesthetist completed a nerve block, they did ‘stop before you block’. This was where the staff double checked they are blocking the correct operation side. A pre-operative patient safety review form was available for patients who fell outside inclusion such as; patients living with learning disability or mental health issues. A RAG rating system (red, green, and amber system) was in place in the preassessment unit. An anaesthetist reviewed all cancellation and postponement. Staff took bloods and patients found to be anaemic or patients with difficult airway would either be postponed or cancelled. Staff rang GPs to prescribe iron infusions where patients were found to be anaemic.

All pre-operative clinical tests were completed in line with National Institute for Health and Care Excellence (NICE) guidelines. Risk assessments to assess a patient’s risk of developing blood clots or venous thrombo-embolism (VTE) whilst in hospital and after surgery were always completed. The VTE assessments were completed, and prophylaxis given in all notes we looked at. The VTE risk assessment was also checked the day after surgery in all records; this was in line with best practice. There was a policy for how to manage a deteriorating patient within the service. There was a team who were assigned to attend any clinical emergency which was led by the Resident Medical Officer (RMO); this was decided daily at the hospital huddle at 9.45am. Staff were supported by the RMO if a patient’s health deteriorated. If the patient could not be managed within the service, they would be transferred by ambulance to the local NHS trust. Staff had access to blood in the event of an emergency, with 4 units of universal blood stored in pathology. Blood products were ordered in advance for patients if it was required. There was a major haemorrhage protocol for staff to follow. There was a theatre huddle at the beginning of each shift with all of theatre and then at the beginning of each surgical list. We observed a huddle and saw they discussed each patient on the list, risks, allergies, medication and equipment needed. We followed a patient journey and saw the WHO checklist, brief and debrief being undertaken in theatre and they were all completed well. All teams performed a brief and debrief for each theatre list. We saw 10 team briefing sheets; all of them were fully completed. There was an on-call team for theatres overnight if a patient needed to return to theatre. There was an inclusion criteria for patients to have surgery at the hospital. All patients attended a preassessment appointment.

Patients could reach call bells on the ward and told us staff responded quickly when called. All patient rooms were single occupancy to prevent any risks of cross infection.

The design of the environment followed national guidance. The service had enough suitable equipment to help them to safely care for patients. There was good availability of equipment within the theatres. They were able to request loan equipment if they did not have it in stock. Staff said there was advanced planning of schedules which meant they could ensure equipment was available. Theatres had a contract with an external company where an engineer attended once a week on a Friday to fix any equipment required. We checked at least 50 items of single use equipment and all of it was in date. Staff told us some of their equipment in theatre was aging and needed replacing; the theatre manager told us this was one of their biggest risks. This was not included as a risk on the departmental risk register. Emergency equipment for the wards was stored in the corridor with clear access. Records indicated that the resuscitation trolleys and their contents were checked daily in line with hospital policy. The trolley was secured with a tag which was removed monthly to check the entire contents were in date. A medical devices’ lead managed medical device issues and provided training on the ward. A fault reporting form was in place and staff completed a decontamination certificate to ensure they were clean prior to sending faulty devices off for repair. Staff gave an example of a faulty blood pressure machine which was sent off for repair and escalated with the Health and Safety Executive at the time. The incident involved staff and no harm was caused. The new modular pre-assessment unit had only one fire exit which had been reviewed by both building control and an external fire consultant as compliant with current fire regulations. We had concerns that in the event of a fire around the fire exit, patients with hip and knee issues might not be able to evacuate the building. However, internal doors were fire doors and a comprehensive fire risk assessment was in place.

The ward area and theatre were suitable for their purpose and the ward area was clutter free. However, we found the theatre corridors were cluttered, and not all equipment was stored appropriately. There was not enough space for all the equipment they had; this was on their risk register and senior managers were aware and were looking at solutions. There were 3 theatres and 1 recovery area with 4 bays but 1 bay was used for storing equipment. This meant at times, patients who were due to come into recovery had to remain in theatres as the other 3 bays were occupied. However, within theatre we found the consumables were stored very neatly within racks and everything was labelled well. All of the anaesthetic rooms were set up the same, this meant staff knew where equipment was even when allocated to different theatres. We found 2 flammable items which were not stored in a metal cabinet on the ward as per Control of Substances Hazardous to Health regulations 2002. We raised this with the theatre team who told us they brought these out at the beginning of each theatre list and immediately locked these away in a metal cabinet at the end of each list. There was a dedicated implant room where all orthopaedic implants were organised on a stacking system and signed in and out of the room. Staff carried out daily safety checks of specialist equipment. We saw all equipment had electrical testing completed. We checked the resuscitation equipment on the ward and in theatre; daily checks were completed in all areas. Theatre staff had access to specialist emergency equipment, such as a difficult airway trolley, and these were checked regularly. However, we found anaesthetic machines were not always checked daily. We looked at 2 different machines and found between 3 and 5 days missing checks each month. We highlighted this to the clinical lead for anaesthetics and recovery and they were aware and were increasing the checks to ensure they were being completed.

There was a resuscitation policy which required staff to check the emergency equipment daily. We saw staff mostly carried out daily checks of specialist equipment. We requested environmental audits for 6 months prior to our assessment. Staff shared an environmental audit on patient areas carried out in October 2023 in theatres. The results did not have an overall compliance percentage. We were not assured that data collected led to quality improvement. The service had processes in place for the maintenance and checking of electrical equipment in accordance with Managing Medical Devices (January 2021), and other national guidance. We saw that 5.7% of equipment logged on the system was overdue a service between the wards and theatres. However, all equipment we checked contained evidence of in date electrical safety testing and servicing. Staff were trained on specialist equipment and had an annual update. We saw staff disposed of clinical waste safely. Within theatres there was a 1-way system for the disposal of waste. The airflow systems in the operating theatres were validated and checked against standards set out in national guidance Health Technical Memorandum 03-01; “Specialised ventilation for Healthcare Buildings” 2021. The service completed an environmental audit annually. This was last completed in October 2023. There were areas of poor compliance such as walls and doors not being in a good state of repair. We did not see the overall result or an action plan associated with it. We were not assured that actions were put in place to make improvements.

The service mostly had enough nursing staff with the right qualifications, skills, training, and experience to provide the right care and treatment. There were 5 vacancies within theatre including scrub nurses, anaesthetic and recovery nurses and a healthcare assistant (HCAs). The department had a lot of new starters including international nurses who had started in April 2024. All new starters had competency booklets to complete. They were all paired up with a member of staff for 1 month to support them. The theatres were staffed in accordance with the Association for Perioperative Practice (AfPP) guidelines. There were enough staff on duty during the patient’s surgical procedure, which included surgeons, anaesthetists, and operating department practitioners. The ward employed 12 whole time equivalent nurses, 5 healthcare assistants and 3 bank staff. The ward manager told us they were in the process of integrating 3 new staff members with 3 additional candidates scheduled for interviews. The preassessment team had 9 nurses, 2 HCAs and an HCA on the bank. An anaesthetist ran preassessment clinics twice a week. Preassessment nurses attended a 3 days preassessment course. Staff were offered opportunities for career development. For example, an HCA had been seconded to attend a nurse associate programme for 2 years. The preassessment lead had just completed an 18-month chartered management institute course for managers. Ward staff received support from an anaesthetist, a RMO and senior nurses out of hours. Sickness levels were low at 4.06% across all clinical departments within the hospital. Staff absences or gaps in the rota were mostly covered with existing staff or bank staff. Theatres used bank staff for 20% of their shifts. The service did not use agency staff; 5 agency staff they previously used had moved over to the bank. Managers made sure all bank staff had a full induction. Turnover in the theatre department was 17.94% in the last 12 months.

During our onsite assessment, we found the number of staff in theatres matched the planned numbers. Staff helped each other out and ensured they worked together to achieve safe care for the patients. We observed an agency nursing staff local induction folder which had been completed when agency nurses attended shifts for the first time.

There were processes in place for bank staff to undergo a local induction. Bank staff booked their shifts using an online application. The theatre manager had a utilisation meeting on a Monday to discuss the following 3 weeks of theatre lists. This meant they were able to plan the staffing in line with surgical activity. Staff were experienced, qualified, and had the right skills and knowledge to meet the needs of patients. Managers made sure staff received specialist training for their role. All staff had competency booklets to complete which were relevant to their role in theatre. Managers supported staff to develop through yearly, constructive appraisals of their work. Data showed 80% of theatre staff had an appraisal within the last 12 months. The theatre manager told us they tried to complete 1-to-1’s every other month with their staff. However, as they had 75 staff, they found this difficult. They had just introduced a new leadership structure in the department with leaders for different areas in the department. These leaders had teams and would be responsible for their 1-to-1’s and appraisals. Managers arranged theatre training days once a month where 1 theatre was closed for half a day, and they had a team meeting and had specific training. They also shut the whole theatre every 3 months for a whole team meeting. There was a board displayed where staff could request certain training. For example, in the next meeting they were having airway training. An anaesthetist also completed practice emergency scenarios; they had recently completed one on major haemorrhage. They also offered simulation and scenario-based training such as difficult airway intubation in theatres. Consultants and anaesthetists were employed on practising privileges (PP). The hospital had a medical advisory committee (MAC) whose responsibilities included ensuring new consultants were granted PP’s if deemed competent and safe to practice.

Staff followed infection control principles including the use of personal protective equipment (PPE). Staff had access to PPE including; aprons, masks and gloves in a variety of sizes. Staff cleaned their hands before, during and after patient contact. We saw signs reminding people to clean their hands in areas we visited. Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned.

Ward and theatre areas were clean, well-organised and had suitable furnishings which were well-maintained. At the time of the inspection, 92% of eligible staff had completed IPC training and 96% had completed practical IPC training. The ward and theatres were cleaned daily by a domestic team or 3 staff. The manager told us they previously had 1 cleaner and were not happy with the standard and this was increased to 3. Theatres also had a deep clean completed every 6 months or after maintenance work was done within the department. Staff mostly followed infection control principles including the use of personal protective equipment. However, we saw 1 staff member in theatre who had gel nails. Hand sanitiser was available in every room and at the entrance to the ward area and theatres. Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned. Reusable surgical instruments were decontaminated off site; there was an efficient process for monitoring this.

Theatre areas were noted to be visibly clean and well-organised. Most staff we saw during our assessment were ‘bare below the elbows’ and dressed in line with the service’s policy. We saw staff cleaning down equipment appropriately following theatre cases. There were separate scrub, anaesthetic, and preparation rooms for each theatre. There were cleaning records available in each area in theatre. However, these records were not all up-to-date and completed daily. Staff told us they occasionally forgot to complete the checklist on busy days.

Guidance was available for staff in the form of an infection prevention and control (IPC) policy. The policy detailed all protocols required to maintain a good level of cleanliness, infection control and hygiene. Audits were completed to assess staffs’ compliance with IPC standards and guidance. The service did not always perform well for cleanliness. There was a cleaning audit performed for the ward and theatres. The most recent results showed compliance of 65% in theatre and 91% in the ward. There were action plans to increase compliance. However, in the theatre action plan the target date for review was May 2024 and this had not been updated since; all the ward actions were closed on their action plan. Hand hygiene audits were performed every quarter. Theatres improved compliance from 83% in March 2024 to 86% in June 2024. The audit contained actions to improve compliance. Audit results were discussed in monthly team and clinical governance meetings.

Staff worked effectively to prevent, identify, and treat surgical site infections (SSI’s). Staff looked at infection data. There were procedures in place to reduce the risk and monitor for signs of SSIs in line with NICE CG 74 Surgical site infections: prevention and treatment. Patients who met the criteria were screened in pre-assessment for Methicillin-Resistant Staphylococcus Aureus before admission. The service completed SSI surveillance 30 days post-surgery for all patients who had had a hip or knee replacement. Between January and June 2024, there had been 7 SSI’s recorded. Data showed there were 0 suspected infections for hip and knee replacements in 2024.

Staff told us that they knew how to contact pharmacy for advice and processes were in place for the supply of medicines. Staff told us how they had access to relevant medicine policies, procedures, and guidelines. The ward had 2 different sepsis kits which included a set ready to go for patients who were allergic to penicillin and another 1 ready for patients who were non allergic to penicillin. Staff said that there was a good relationship with the pharmacy team. The ward had a medicines management lead who worked with a pharmacy technician to check expiry dates regularly. Pharmacy was available to support them with managing medicine processes such as feedback from audits on medicine management, ordering and receiving medicines. There was a medicines management lead for theatres. They attended quarterly medicine management meetings and actioned any requirements from it.

We observed that medicines were locked and secure. We saw medicines were always stored safely in line with recommended practice. Medicine storage and security checks were undertaken and recorded regularly. Controlled drugs (CDs) were stored safely and securely with access restricted to authorised staff. Checks were undertaken and recorded by 2 staff daily. Checks of CDs showed that they were within date and stock balances were accurate. Medicines for refrigeration were stored securely. The maximum and minimum temperatures were taken electronically and monitored by the pharmacy department to ensure the medicines were stored safely. Staff knew how to escalate any temperature breaches and what action to take to ensure safe medicine storage. The ward had 2 medicines trollies which were on wheels. Staff moved them around when doing drug rounds and we observed these were locked when not in use. We reviewed the CDs book on the ward and found 3 discrepancies in the recording of some CDs. For example, a signature, dose or time of administration was missing. Pharmacy staff audited the CD book. We requested audits carried out on missed doses and actions taken. We were told the last audit was done in May 2024 and the audit for the current quarter was not due. The pharmacy manager raised the discrepancy as an incident and assigned the ward manager to investigate. Documentation of medicines administration including routes of administration and specific times of administration were clear on all medicine records reviewed. Allergy status of patients was routinely recorded on all medicine records seen. Processes were in place to record pain assessments and that appropriate pain relief was prescribed, administered, and recorded.

Staff followed systems and processes to prescribe and administer medicines safely. Doctors prescribed medicines on a paper-based chart. This was stored within patients’ nursing record. There was a clear process in place for managing and reporting any incidents involving medicines. Staff were able to talk through the process that would be followed if this occurred. There was a good safety culture that encouraged staff to report these. The keys for the medicine cupboards and CD cupboards were kept in a key safe throughout the day. When the area was closed, the staff put all the keys in one CD cupboard and then put the CD cupboard key into a tamper proof coded sealed bag which was taken to the ward. This number was then checked the following morning for on collection to ensure the keys had not been used. Patients were given advice at the pre-operative assessment regarding stopping certain medications which may interfere with their procedure; we saw documentation in patients notes regarding these conversations. Regular audits were carried out to ensure medicines were reconciled, prescribed, administered, and stored in line with national guidance and hospital policy. The ward and theatre should complete quarterly CD audits. However, we were only sent the audit from October 2024 for the ward. For both theatre and the ward, the results did not have an overall compliance percentage. There were actions plans for both, but the theatre action plan had not been updated since the quarter 4 audit in 2023. Both the ward and theatre had a medicines security audit completed in February 2024 and theatre also had completed one in June 2024. They scored 93% and 96% respectively. Where non-compliance was found, these issues were documented but actions were not created. There was no responsible person or date for the action to be complete by.