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

We reviewed the learning culture, safeguarding and safe environments quality statements for the safe key question. There was a culture of safety and learning. This was based on openness, transparency and learning from events that have either put people and staff at risk of harm, or that have caused them harm. Lessons were learned from safety incidents or complaints, resulting in changes that improved care for others.

There was a strong understanding of safeguarding and how to take appropriate action. Staff could discuss situations where they had escalated concerns. The design of the environment followed national guidance for safety.

All patient rooms were of single occupancy to maintain privacy, dignity and to prevent any risks of cross infection. Staff carried out daily safety checks on specialist equipment to ensure they were in good working order. The service had suitable facilities and equipment to safely meet the needs of patients and their families. The service had enough skilled staff to care for patients and keep them safe.

However, medicines were not always stored at recommended fridge temperatures.

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.

Staff were encouraged to report incidents and received feedback from incidents they reported. Staff felt confident to raise concerns and were clear about who to report concerns to. The service had no ‘never events’ in the previous 12 months. From January 2023 to July 2024, there had been 98 incidents reported across the service with 19 classified as no harm, 67 as low harm, 10 incidents as moderate harm and 2 incidents as death within 30 days. Staff we spoke with in medical services understood their responsibilities to meet the duty of candour and to be open and honest with patients when notifiable incidents occurred. The duty of candour requires registered providers and registered managers (known as ‘registered persons’) to act in an open and transparent way with people receiving care or treatment from them. Staff gave patients and families a full explanation and apology when things went wrong in line with the duty of candour corporate policy.

The service had appropriate corporate policies and local procedures to guide staff. There were processes in place for staff to follow when reporting incidents. Incidents and complaints were appropriately investigated and reported. We saw reports from an investigation of incident which showed managers investigated incidents thoroughly. There was evidence that changes had been made as a result of identified learning. Staff shared feedback which related to an incident where a central line was used to administer antibiotics following a suspected sepsis infection. Staff undertook a thorough multidisciplinary team review including actions and shared learning following the specific incident. The hospital senior leadership team attended Nuffield’s national group meetings where learning from incidents were discussed. Learning from incidents was shared with staff during regular ward meetings and during Outcomes with Learning meetings. Senior staff shared safety alerts and ensured actions were implemented in line with national guidance.

All patients attending the Milverton suite for chemotherapy had access to a patient led app which provided them with essential information including support pathways for contact when treatment complication occurred. Patients told us they had a pharmaceutical care plan and could record medicines they were on including side effects, pain status and their feelings using the app. Staff reviewed these and made contact with patients who required support and worked proactively to improve outcomes. We observed a clinical nurse specialist reviewing patient feedback during our assessment.

Discharge nurses gave patients booklets and advised them to make contact to the endoscopy department or emergency department if they experienced any complication following their endoscopy procedure. Nurses also shared out of hours contact details including numbers of who to contact at weekends.

Staff completed a pathway document for patients attending an endoscopy procedure. This comprised of a detailed pre-operative assessment including; patient’s medical and anaesthetic history, previous hospital admissions, any medication they were taking, and daily living arrangements.

There was an electronic system in place to generate endoscopy reports and these reports were shared with patients and their GPs.

Since June 2024, all patients received a phone call from the endoscopy department 30 days following their procedure to ascertain if they had any complications, mortality or mobility following the endoscopy procedure. Patients would also be asked if they had received care in an NHS hospital linked to the endoscopy procedure or if they had either seen their GP or taken any antibiotics linked to their procedure.

There was a process and guidance in place which required any polyps above 2cm to be left unremoved and referred to a local NHS trust to keep patients safe from the risk of bleeding.

Notes for patients attending for chemotherapy were stored online and staff stored paper records in locked cupboards in the nursing office.

An operations register was available in the endoscopy procedure room for staff to record information such as patient names, date of birth, biopsies taken and information around sedation and pain relief administered. A specimen book was also available for staff to record specimens taken. This was signed by two staff and sent off to pathology for processing.

Staff received training specific for their role on how to recognise and report abuse. Staff in all areas had access to safeguarding information about how to refer and escalate concerns. Staff escalated safeguarding concerns to the ward manager. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them. Staff gave examples of concerns they would report and knew the contact details of the agencies they would report to.

The safeguarding lead for the service was the director of clinical services who worked on site; they were trained to level 3. They were able to support staff in escalating their concerns and supporting referral processes to the relevant local authorities.

There were effective systems, processes and practices to make sure people were protected from abuse and neglect. An up-to-date safeguarding vulnerable adults policy, with flow charts for the escalation of concerns was available. The service had a process in place to monitor staff training to ensure they were in compliance with the hospital’s target. Information was provided which demonstrated 100% of staff were trained in level 1 and 2 safeguarding for both children and adults, and all staff who required level 3 safeguarding training for children and adults had completed this.

The hospital had a defined recruitment pathway and procedures to help ensure that the relevant recruitment checks had been completed for all staff. These included a disclosure and barring service (DBS) check; occupational health clearance, references and qualification and professional registration checks.

We did not ask users about managing risks. However, we saw ‘just ask, could it be sepsis?’ leaflets displayed on the endoscopy unit during our assessment. The leaflet provided patients and their relatives with information around symptoms in adults, how to spot sepsis and emergency contact numbers if someone had one of the sepsis symptoms.

Staff made sure patients and those close to them understood their care and treatment.

Staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration. Staff used a nationally recognised tool to identify deteriorating patients and escalated them appropriately. Staff used the national early warning score (NEWS2) tool to assess patients at risk of deterioration. From January to June 2024 (Quarter 1 and 2) the NEWS2 audit for oncology revealed 93.9% compliance. Staff knew about patients with a medical history which represented an increased risk. Staff knew in advance when patients with additional needs were attending and planned to meet these needs and reduce risks posed to them. This included patients with reduced mobility that may need more assistance. All patients attended a pre-assessment clinic prior to their endoscopy appointment. This was run by registered nurses who checked past medical history and general safety information to determine if the patient was fit for the procedure. On the day of the endoscopy procedure, nurses checked what patients had been asked during the pre-assessment session to ensure their condition had not changed. Patients who attended to receive chemotherapy had a peripheral and central line. Staff shared an example of an incident which related to sepsis and how this had been well managed.

Patient assessments were carried out to manage risks in line with national guidance. Risk assessments were undertaken in areas such as venous thromboembolism (VTE), falls, malnutrition and pressure sores. These were assessed and documented in the patient’s records in line with best practice.

Records included risk assessments for VTE, pressure areas and nutrition. Staff had completed all assessments in the records we reviewed.

There was a hospital wide policy in place which the service was aware of for managing and escalation of a deteriorating patient. This provided staff with the information they required to ensure the situation was managed well regardless of where the emergency occurred.

Staff followed policies and processes in place to complete individual risk assessments for patients who attended for endoscopy and oncology procedures.

There were processes in place to risk assess patients undergoing a procedure within the department. During our assessment, we observed the endoscopy team used the five steps to safer surgery, which included the World Health Organisation (WHO) surgical safety checklist. The WHO checklist is a nationally recognised system of checks designed to prevent avoidable harm and mistakes during surgical procedures. These checks consisted of team briefing, sign in (before anaesthesia), time out (before surgery starts), sign out (at the end of the procedure) and debrief. We observed all five steps of the WHO checklist and saw staff fully completed and engaged in all the required checks. The documentation of pre-list team briefing and post-list debriefing was found to be consistent on all 4 endoscopy records we reviewed. This had improved since our last inspection. WHO checklists and Local Safety Standards for Invasive Procedures were used within the endoscopy department and audits completed for compliance purposes. The results showed 100% compliance with the audits for the service.

The design of the environment followed national guidance. The endoscopy unit had 6 ensuite rooms with 6 beds including a room suitable for wheelchair users and a procedure room. The unit had no recovery area as patients were recovered in individual rooms. There was a decontamination area and the clean and dirty utility areas were separated.

The oncology suite was called the Milverton suite. It had 4 treatment rooms with reclinable chairs used for patients who attended for chemotherapy.

All sharps and cytotoxic (a substance that kills cells, including cancer cells) clinical bins were fully compliant with HTM 07/01 good streaming of waste. We were shown a waste bag film sealing device for safe disposal of chemo waste which was fully compliant with HTM 07/01 (The safe management/disposal of healthcare waste 2013). The bags were compacted, removed from the device weekly and taken to the holding waste outside the compound for safe disposal. All porters had completed a cytotoxic handling course and there was an appointed cytotoxic champion for each area.

The service had suitable facilities to meet the needs of patients' families. There were individual rooms and patient privacy was maintained at all times. The endoscopy ward and Milverton Suite environment and equipment were clean and free from dust. Rooms were clean and tidy. The layout was clutter free. Damaged or faulty equipment was repaired quickly. We reviewed equipment logs and saw equipment used was serviced within appropriate time frames. Stock and equipment, including disposable instruments, were well managed and recorded.

We saw a quick reference guide for dealing with cytotoxic spillage on the wall in the treatment room. We observed 3 spillage bags in the treatment room on Milverton suite. There was clear guidance around dealing with a spillage including donning and doffing of personal protective equipment.

Fire extinguishers and all equipment including hoists across all areas we visited had been service tested. Fire exits were found to be clearly signposted and free from cluster. The endoscopy procedure room had a wall mounted oxygen suction, a call bell and an emergency call bell. Patients attending Milverton Suite for chemotherapy had access to recliner chairs in the rooms, which they could use instead of the bed during treatment.

There was a process in place locally to ensure all equipment was safely managed. The hospital had existing maintenance and repair contracts for all equipment used in endoscopy. There were lockable cupboards for the storage of hazardous cleaning chemicals, which met the Control of Substances Hazardous to Health regulations 2002 (COSHH). Staff disposed of clinical waste safely. Clinical waste disposal was provided through a service level agreement. Clinical waste and non-clinical waste were correctly segregated. There was a tracking system used to log equipment and scopes used in the endoscopy unit. This enabled traceability of endoscopes as required.

The service mostly had enough medical, nursing and support staff to keep patients safe. The endoscopy service had 12 consultants who carried out lower and upper endoscopy procedures. They employed 5 nursing staff with 1 wholetime equivalent, 3 part time staff and 1 endoscopy lead.

Leaders kept staffing numbers at a safe level with a suitable skill mix increasing numbers as much as possible across endoscopy and oncology. They used bank staff when necessary, ensuring they were familiar with systems and processes.

Staff received and kept up to date with their mandatory training. The mandatory training was comprehensive and met the needs of patients and staff. They had effective supervision and annual reviews of their work, and discussions about future learning and development opportunities.

The hospital set a target of 90% for completion of all mandatory training courses. The hospital data showed an overall 93.8% compliance for medical, nursing and non-clinical staff which was better than hospital target. Managers monitored mandatory training and alerted staff when they needed to update their training.

The service completed Basic Life Support and recorded 63% compliance with this and 77% in immediate life support. Staff had been booked onto courses over the following few months to increase compliance. All staff and managers were sent reminders when training was overdue.

The pharmacy team had 6 pharmacists including a bank pharmacist in post. An agency pharmacist was available to provide cover as required.

Managers supported staff to develop through yearly, constructive appraisals of their work. Data showed 100% of endoscopy and oncology staff had an appraisal within the last 12 months.

Consultants provided training and education sessions for staff. Staff had attended external courses such as advanced communication, safer cancer care conference, oncology nursing society 2-day forum and the national cancer colorectal network Clinical Nurse Specialist educational day.

Endoscopy staffing numbers did not always match with the acuity. The unit had 5 substantive staff. Staff were being moved from theatres to cover lists within the endoscopy department. We were not assured staff providing cover in procedure rooms had sufficient competences to enable them undertake roles such as airway management. We raised this with senior staff at the time of our assessment. We were told the service always had sufficient staffing levels in accordance with the Joint Advisory Group recommendations.

There were mostly processes in place to ensure there was enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.

New starters including those working under bank received a local induction as part of the processes in place to ensure staff were safely inducted to the local area.

The service had processes in place to monitor staff sickness, vacancies and turnover. From July 2023 to July 2024, the service reported turnover rate of 17.9% which included theatres turnover. They reported sickness rate of 4.06% across all clinical areas including theatres and 1 full time vacancy in endoscopy.

Managers reviewed the staffing numbers each day and discussed staffing during the morning huddle.

The service made sure staff were competent for their roles. Where necessary and where staff had identified areas for further training, staff underwent further competency assessments. Managers monitored performance and stored hard copies of staff training and competencies in various areas we visited.

Records showed the nursing and healthcare assistants mostly achieved the approved staffing numbers but were supplemented at times by bank staff.

All pharmacy staff had British Oncology Pharmacy qualification to keep them up to date with oncology issues.

There were arrangements in the areas we assessed in medical services, to comply with infection prevention and control procedures. The service had undertaken a legionella and a fire risk assessment. Water outlets and sinks were flushed to reduce the risk of legionella and pseudomonas build-up in line with Health and Safety Executive (HSE) guidance. Staff completed a general health and safety risk assessment. We found the testing for pseudomonas was overdue. We raised this with senior staff as we were concerned patients attending could be exposed to microorganisms which could put them at risk of infection. In response, staff booked the next water testing visit during our assessment.

There were arrangements in place in the endoscopy service to clean scopes and equipment in line with guidance, including Health Technical Memorandum 01-06: decontamination of flexible endoscopes. For example, used scopes were placed in a tray with a red plastic cover to indicate potential hazard. There was a separate ‘dirty’ room adjacent to the endoscopy room where used scopes were cleaned and processed through a disinfecting machine. There was a clean area, outside of this room where scopes were stored.

We observed staff adhering to policies, such as ‘arms bare below the elbow’ to allow effective handwashing and using personal protective equipment (PPE) appropriately. For example, wearing apron and gloves when inserting a peripheral venous access. Staff cleaned their hands in line with World Health Organisation five moments for hand hygiene. Staff used Aseptic Non-Touch Technique (ANTT) to prepare chemotherapy bags in treatment rooms before taking them to patients. Staff used special aprons and gloves to administer cytotoxic medicines. We observed an immunotherapy being administered. This was checked by 2 staff and they used ANTT technique during the administration. Staff cleaned equipment after patient contact and labelled them to show when it was last cleaned. ‘I am clean’ stickers were used throughout the department.

All soft furnishing were wipeable and compliant with HBN 00/09 (infection control in the built environment). Hand-washing and sanitising facilities were available for staff and visitors. The endoscopy procedure room and all flooring was fully compliant with HBN 00/09 infection control in the build environment.

There were policies and processes in place for staff to follow to ensure the risk of infection was controlled well. 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. Staff carried out observational hand hygiene and environmental audits in both endoscopy and oncology. Hand hygiene audit showed 98% of compliance in quarter 2 in 2024. Overall management of IPC audit in 2023 was 94%. Cleaning records were up-to-date and demonstrated that all areas were cleaned regularly. Managers completed cleaning validation audits monthly.

Staff knew how to contact pharmacy for advice and processes were in place for the supply of medicines. Staff had access to relevant medicine policies, procedures, and guidelines. All chemotherapy was double bagged and staff administering them used specialist equipment which prevented leakage and exposure risk. Staff kept a wasted chemotherapy log which detailed the date, drug value and the reason for wastage.

All staff handling cytotoxic medicines had received training. We reviewed chemotherapy regimen for 3 patients and found allergies had been clearly identified with regular monitoring of chemotherapy including blood result checks. Any anomalies were clearly identified, and action taken when patients received chemotherapy treatment.

A clear sign in and sign out process was in place for both Endoscopy and theatre staff to collect controlled drugs keys from the ward.

Medicines such as sedation and opioids for pain relief, used for endoscopy procedures, were checked thoroughly against the controlled drugs (CDs) book. Nurses signed the CDs book following each administration. However, we observed doctors did not always sign following each administration which was not in line with published guidance.

Staff did not always store medicines in line with the manufacturer’s guidance. The treatment room contained pharmacy fridges and a medicine fridge used by nurses. Fridge temperatures were monitored using a centralised transmitter system. On day 1 of our onsite assessment, we found fridge temperatures were out of range with some above 12°C and below 2°C for less than 5 minutes on 8 occasions in May 2024. Although the average temperature was always within normal range, the maximum temperature exceeded 8°C from 18 June to 5 July 2024. Some medicines should be stored at temperatures between 2°C and 8°C as per guidance. We raised this with the pharmacy team at the time of our assessment and they reviewed medicines stored within the fridge. We were told the system took an average of 3 singular readings to trigger an alarm. The service had a standard operating procedure which detailed actions staff should take following a temperature breach. Staff raised incidents when alarms were triggered. However, they reviewed and closed them if the alarm was a singular point of 5 minutes. Staff recognised the risk of the transmitter being offline and Wi-fi connectivity issues as a risk on the hospital’s risk register. The pharmacy team did not escalate the amount of times temperatures were out of range as they were usually out of range between 5 to 10 minutes. There was a risk of medicines losing their effectiveness. We were not assured medicines were always stored at recommended fridge temperatures.

Staff followed systems and processes when prescribing, administering and recording medicines. A comprehensive medicines management policy was in place, which covered obtaining, prescribing, recording, handling, storage, security, administration and disposal of medicines. There were processes and systems in place for the oncology service to manage chemotherapy medicines. The pharmacist checked all prescriptions, monitored potential errors and recorded all interventions that they made. Consultants prescribed the chemotherapy treatments against the British Oncology Pharmacy Association guidelines. A chemotherapy advisory group was available online. Chemotherapy regimens were verified by this group and consultants prescribing them were able to select a regimen online. The prescribed chemotherapy regime was sent to the pharmacy, which was based in the hospital. Chemotherapy was made up offsite under a service level agreement and delivered in cytotoxic transportation bags. Medicine records were completed appropriately and these included allergies and venous thromboembolism assessments. Medicines were in date and stored in secure locked cupboard. Controlled medicines were regularly reviewed and audited to ensure the hospital complied with the standard operating procedures and regulations.