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Birmingham Children's Hospital Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 21 February 2017

We conducted this inspection from the 17-20 May 2016. We returned to the hospital for an unannounced to see the hospital services outside of core business hours.

This is a specialist trust and we made a public commitment to inspect these before June 2016. We held no other intelligence to have raised the risk to require us to inspect before this date.

We conducted this inspection under our comprehensive methodology, giving the trust notice of our inspection. This enabled us to request information prior to the inspection, review information we held about the trust and speak with stakeholders of the trust. We inspected the main site, based in the centre of Birmingham. We also inspected Forward Thinking Birmingham this is a mental health service offered to young people up to the age of 25yrs. The services offered care both in-patients at Parkview and within community hubs.

Please note the service offered under Forward Thinking Birmingham had commenced fully April 2016 just prior to our inspection. BCH (Birmingham Children’s Hospital) is the lead provider of the service delivered by a consortium. The inspection findings are in separate reports.

Please note when we refer to Paediatric intensive care unit (PICU) we are describing to critical care for children and young people.

We rated the hospital ‘outstanding’ overall;

Our key findings were as follows:

  • Staff understood how and the importance of raising incidents. Learning was shared amongst the staff group to keep improving quality.The trust had started to report excellence and sharing learning when things when well.

  • Multidisciplinary team working was embedded in the trust.We observed this in action.

  • The feedback from parents and children was positive, with them reporting they were treated with respect and dignity.Bereaved parents described the compassionate care they received from the staff.

  • Results of surgical outcomes demonstrated the team performed better or the same as comparable services.

  • We noted how responsive the trust was, for instance, they were piloting a service with the aim to reduce readmissions to the hospital by having health visitors conduct follow-up calls to patients who had been discharged form ED.

  • As the trust served patients and parents from outside of the Birmingham environs, parents were able to use nearby accommodation free of charge.This allowed them the opportunity to stay near by their child whilst they were receiving treatment.They were also able to seek support from other families using the accommodation.

  • All cancer referrals met the treatment targets, and 100% of all children were seen within six weeks of referral.

  • Safer staffing tool demonstrated there was enough nursing staff to meet patients’ needs supplemented by bank staff.Staffing sickness rates were below the England average.

  • The trust had a strategy in place to ensure it met its vision. Systems were in place to ensure the board were aware of any risks that could prevent it from meeting the vision.

  • Staff were aware of the values and were assessed against them as part of the appraisal process.

  • The leadership was well respected amongst the staff group and were effective, with succession planning in place and a board development programme.

  • The culture was one of support of each other, staff referred to ‘Team BCH’, and using opportunities to listen to patients carers and visitors.

  • Seven never events had occurred in surgery.This had resulted in the theatre team being investigated internally to try to identify a pattern and areas for improvement.The trust had commissioned an external company to help them identify areas of improvement.A theatre task force was in place to drive the momentum.

  • There had been outbreaks of reportable infections, and we saw that improvements were needed regarding hand hygiene in neonatal services.However, we did find most areas to be visibly clean.

  • Consultant staffing levels in neonatal did not meet the best practice guidelines.There was a vacancy rate of 26% in child and adolescent mental health services (CAMHS).

  • We saw there were a lack of up to date care plans in place for (CAMHS) patients and a lack of outcome data for neonatal services.

  • PLACE scores returned demonstrated that patients were not fully satisfied with the food.The trust had done work to improve the food with the support of dieticians and the introduced defined meal times.This included feedback place mats and music for example.

  • PICANET data (2014) demonstrated that standardised mortality ratios were within expected range.

We saw several areas of outstanding practice including:

  • Within medical care, we saw outstanding use of storytelling therapists to help with children’s emotions, anxiety and distress during their stay in hospital, and to help to explain treatment processes to them.Following a session of storytelling therapy, one parent reported their child had not asked for their usual pain relief overnight.

  • On the PICU, a safety huddle (a safety briefing meeting) was held three times throughout the day to review patients and the PICU patient flow.An additional safety huddle was held at 4.30pm during the inspection, as patient demand was greater than capacity, which was attended by the Medical Director who was on call that evening.This was outstanding practice with team involvement for safety.

  • The trust has implemented a Rare Diseases Strategy, which will deliver an innovative approach for children who due to their rare or undiagnosed condition would be required to attend multiple outpatient appointments with a variety of specialities.The Rare Disease Centre will enable all clinicians involved in the care of the child to be present to provide a holistic approach in one appointment.

  • Transition services demonstrated a service which was actively supporting young people to moveinto adult services.Serviceswere offered both in and out of the hospital, and the multidisciplinary team worked in a cohesive fashionsuch as joint clinics.

  • End of life core service supported children and young people and their families during palliative care and at the end of their life.Services were responsive, with referrals accepted within 24 hours. Urgent discharges were achieved within 24hrs so children and young people could die where they requested.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • The trust must take action to ensure that learning from serious incidents involving neonates ward are shared consistently across the trust.

  • Review governance processes to ensure neonatal services assess, monitor and mitigate risks to all neonates across the trust. This should include reviewing the neonatal governance structure and morbidity and mortality meetings.

  • Radiology must ensure that a radiologist is always available for advice and for protocolling CT and MRI examinations.

  • Within CAMHS community, the trust must ensure there are sufficient numbers of skilled and qualified staff to provide an effective service.

Please note more outstanding practice and ‘must’ and ‘should’ actions can be found at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 21 February 2017

Effective

Outstanding

Updated 21 February 2017

Caring

Outstanding

Updated 21 February 2017

Responsive

Outstanding

Updated 21 February 2017

Well-led

Good

Updated 21 February 2017

Checks on specific services

Medical care

Outstanding

Updated 21 February 2017

Overall, we rated medical care at Birmingham Children’s Hospital as outstanding. Safe was rated good.

  • There was a positive, transparent culture of incident reporting and learning from incidents. Sufficient numbers of appropriately qualified and trained staff were on duty to ensure patients were kept safe.

  • Staff used national guidelines and evidence-based treatment when looking after patients. The hospital took part in several national audits and staff were encouraged to carry out local audits. Results of audits were used to improve patients’ experiences and care.

  • Feedback from parents and patients about the care they received was consistently excellent. Parents, carers and patients we spoke with said staff “went the extra mile” and were “brilliant” or “excellent” and the care given was much more than they expected.

  • Patients and their families were treated with respect, dignity and compassion, particularly at the most difficult times Parents were involved at every stage and were treated as individuals.

  • Patients were treated as individuals and different approaches were taken, when needed, to care for them in the most appropriate way. Staff supported people from different cultures, backgrounds and religions and made adjustments to accommodate their needs.

  • Leaders had an inspiring purpose and common focus to deliver the best possible care to the children in their care, and this attitude was shared by staff at all levels. Staff across all groups were proud of the organisation as a place to work and spoke highly of the culture. Many staff told us the hospital was “the best place they had ever worked” and said they “couldn’t imagine working anywhere else”.

Urgent and emergency services (A&E)

Good

Updated 21 February 2017

We have rated this service as good. This is because:

  • There was a clear process for reporting incidents, staff knew how to report incidents and received feedback when they did.
  • We saw that lessons were learnt when things went wrong, actions were taken and practice changed as a result.
  • Paediatric early warning scores were recorded during the triage assessment which meant that each child’s condition was closely assessed and monitored.
  • Staff were trained, competent and followed evidence based practice and national guidance.
  • Staff contributed to a range of local and national audits including those led by the Royal College of Emergency Medicine (RCEM). The RCEM reviewed the submitted data and developed action plans with the findings.
  • Staff were kind, caring and compassionate towards children, young people, and their families. They were pleased with the level of care and treatment they received in the department.
  • The service had a plan in place to ensure services were delivered to meet patient needs over the winter period.
  • Patients with complex needs and learning disabilities were supported with specialist care.
  • An admission avoidance board updated attendees about alternative support available to them in the community which could mean they were seen quicker elsewhere.
  • The department mostly met the target for patients been seen and treated within 4-hours. Where the 95% target was not met, the departments was above the England average.
  • Staff were aware of the vision and values of the trust and felt the challenges of the department were understood and their commitment was valued and respected.
  • There was a clear strategy for the future of the service.

However we also saw that:

  • In the observation unit, children in the unit were without identification bands in place, which meant their identity, could be difficult to determine; two of which had received prescribed treatment. We observed the unit was left unstaffed for over five minutes.
  • There was limited space for medication preparation in the resuscitation area.
  • The waiting area was at times overcrowded and unkempt, with no domestic service to clean away the litter or attend to the public facilities.
  • There was limited information for parents and patients on how to complain if they were unhappy about the service.

  • The risk register did not correspond with the risks within the department with staff anxieties relating to major incidents not being acknowledged. We were not assured that all risks were being addressed.

Neonatal services

Requires improvement

Updated 21 February 2017

We rated this service as ‘requires improvement’ because we rated safe as inadequate. Effective and responsive and well led as requires improvement with caring rated as good.

  • This service lacked clear identity, strategy and clinical leadership, which affected all aspects of care for neonates at this trust. Neonates could be cared for within any department of the hospital; we saw variation in the care babies received dependant on their location.

  • This trust had two external reviews of their neonatal service dating back to January 2015 and January 2016 respectively.

  • Nurse staffing levels did not meet national standards because of the increased number of babies on NSW requiring high dependency care.

  • The trust did not collect adequate data on the quality and performance of neonatal care; this is a national standard. The trust was not fully using the gold standard of the neonatal network IT system to aid effective communication and care planning.

  • This service did not always investigate serious incidents because of the lack of recognition of the severity or the potential harm to babies. Senior management lacked this understanding and therefore opportunities to learn from serious incidents were lost. Senior managers also lacked knowledge of risk register management.

  • We found several concerns with the safety of the environment and equipment.

  • The provision of neonatologists’ from the local maternity unit was not meeting the service level agreement of four hours neonatologist presence Monday-Friday. Senior management described the relationship between surgical paediatricians and the neonatologists’ as ‘unengaged’. Following the inspection we had information from the trust to demonstrate that improvements had been made.

  • Mandatory training for registered nurses on the neonatal surgical ward fell below the trust target.

  • Safeguarding children training for both nursing and medical staff fell below the trust target.

  • Nurses working in neonatal care services require specialist training. There was no clarity on the number of staff required or eligible to complete specialist training, or which course they would be required to complete.

  • All levels of staff lacked awareness of the full duty of candour process. Staff did not always recognise the seriousness of incidents and therefore missed opportunities to learn. This increased the risk of them not recognising when duty of candour applied.

  • Staff were not aware of a missing child policy. A baby was abducted from NSW in July 2015.The policy was not a standalone policy but since our inspection, the trust said it was addressing this.

However:

  • The trust was responsive to the concerns we highlighted following our inspection with immediate actions taken to address leadership and service issues and a strategic plan was made.

  • There was a date set for public involvement to discuss the future of the service and to influence improvements.

  • The neonatal surgical outreach team was responsive to the individual needs of surgical neonates and provided cross-organisational boundary care to meet these needs. This service had a clear strategy and demonstrated effectiveness of reducing cot days at the trust and out of region transfers.

  • Staff were aware of how to report incidents and received some feedback.

  • We observed good multi-disciplinary working between professionals.

  • Parents praised the care that staff gave their babies and this shown in parent feedback and nominations for local awards. Staff demonstrated the trust values and described the culture as ‘team BCH’.

  • The records we viewed met national standards for record keeping.

  • The trust had a process in place for assessing and responding to deteriorating children with the provision of the PACE team.

Transitional services

Outstanding

Updated 21 February 2017

Overall we rated the service as outstanding because:

  • There was a holistic approach to planning patient’s transition to other services, which fully reflected individual circumstances and preferences.

  • We found there was a real passion and commitment across multidisciplinary teams to deliver a patient centred and high quality service for young people and adolescents (patients) transitioning to adult care.

  • There was a transitional care policy for young people with long term conditions and/or disability (the policy) that encompassed the activities needed to support patients transitioning to adult care.

  • The was an Adolescent and Transition Forum (A&TF) to ensure the policy was implemented and Young Person’s Advisory Group (YPAG) which had the remit to support and monitor the use of the policy.

  • The progress on implementing transition pathways for individual specialties was varied. There were 36 specialities where transition arrangements were either in place and well established or some in the earlier phases of development. Progress was dependent upon the complexity and rarity of individual medical conditions.

  • There were a number of specialties participating in national research programs and used the outcome of these to develop innovative and pioneering approaches to high quality care for patients transitioning to adult care.

  • Patients received treatment and care according to national guidelines. Transition services obtained good quality outcomes as evidenced by a range of national audits such as the Royal College of Paediatric and Child Health (RCPCH) and the National Institute of Health and Care Excellence (NICE) as a basis to quality assure its transition services.

  • Transition services used the Department of Health ‘You’re Welcome’ self-review tool, ‘Quality criteria for young people friendly health services, 2011’ to monitor standards via the Commissioning for Quality and Innovation framework (CQUIN).

  • Feedback from patients and parents were positive, children and young people were treated with dignity, respect and kindness. Staff communicated with patients and their parents and provided information in a way that they could understand.

  • Transition clinical leads and champions felt valued and supported by their managers and received the appropriate training and supervision to enable them to meet patients’ individual needs.

  • There were a range of examples of transition plans. Specialties used innovative and efficient ways to deliver more joined-up care to patients transitioning to adult care. There was a holistic approach to planning people’s transition to other services.

  • The service involved other organisations and there were examples of the local community being integral to how services were planned and ensured that services met patient’s needs.
  • Transition teams had reviewed its framework and processes for governance to support patients transitioning into adult care.

  • Staff we spoke with, minutes of meetings, monitoring data and audit of transition pathways demonstrated the governance processes for transition services were in place for the majority of specialities.

  • There was a YPAG which was proactive in ensuring patients were involved in the development, design and delivery of services for children and young people.

  • There was an open, transparent culture with a clear vision and strategy for transition services which was led by a strong management team. Staff told us and we saw evidence that they were consulted and part of the development of the strategy, they were engaged and enthusiastic about the new developments within the transition service.

However we found:

  • Not all specialities used the trust’s documentation. Plans to support transition for the remaining 16 of the 36 specialities needing amending or further embedding.

  • A centralised approach to how information was shared with other external providers when taking over the care of patients transitioning to adult care was in the process of being developed.

  • Further work was needed to formalise governance processes so themes and areas of concerns specifically relating to transition could be identified and acted upon in a more timely and effective manner.

  • Through conversations with transition clinical leads and champions there was a development opportunity to create a better understanding and appreciation of the needs of adolescents transitioning to adult care.

Surgery

Good

Updated 21 February 2017

We rated this service as good because, with the safe domain being rated as requires improvement:

  • Staff understood how to report incidents and managers shared learning from incidents across the surgical directorates.

  • The surgical wards and theatres we visited were clean and tidy.

  • Managers used recognised tools to determine staffing levels and skill mix, and they put systems in place for continuity of services.

  • The surgical directorates followed National Institute for Health and Care Excellence (NICE) guidance and nationally recognised best practice.

  • Staff used national and local audits to monitor patient outcomes and identified opportunities for improvements.

  • The acute pain team provided effective treatment to patients.

  • We saw minutes from a multidisciplinary team (MDT) meeting and observed good working relationships between staff.Nursing staff understood their role and were up-to-date with their specialist training, appraisals and supervision.

  • Staff provided a professional, caring and compassionate service to patients within a calm ward atmosphere.Family members confirmed this in person as well as through comments in the NHS Friends and Family Test (FFT) questionnaire.

  • Birmingham Children’s Hospital is aleading UK specialist paediatric centre, which delivers surgical services for young people from across the country.

  • The hospital kept older children and teenagers of the same gender together and did not place them in mixed sex wards.

  • Staff managed bed availability to ensure they could admit patients as required.In addition, we saw an effective MDT working with complex needs patients.

  • There was a clear vision within the surgical directorate.Staff were positive about proposals to merge the hospital with a neighbouring trust whose services complemented their own.

  • A clear governance system was in place and was effective in delivering a good service to patients. Staff felt supported by managers and described positive leadership and an open door policy.

  • Many innovative practices took place within the surgery directorate including the ‘intent day’ where staff were actively involved in creating their own values. In addition, an ‘app tree wall’ (a picture of a tree) displayed children’s, parents and families’ feedback on the service.

However:

  • Despite staff sharing information in relation to surgical ‘never events’ (serious, largely preventable patient safety incidents that should not occur if proper preventative measures are taken), avoidable mistakes continued to happen.

  • We saw evidence of engagement with other trusts in relation to information sharing about never events, but there was no exchange of staff between trusts or peer review of practice, which may have reduced the number of never events.

  • The trust had two inconsistent computer systems, which monitored staff training. One system would suggest that a particular member of staff had completed training while the other suggested they had not.

  • We found staff were honest and open with patients; however, not all staff understood the point at which the trust became legally obliged to follow Duty of Candour procedures.

Intensive/critical care

Outstanding

Updated 21 February 2017

Safety was rated as outstanding because:

  • The Paediatric Intensive Care Unit (PICU) and high dependency unit (HDU) had clear, effective systems and processes in place within this service to promote safe and effective holistic care.

  • Staff understood their roles, responsibilities and was proud of how the service had developed, including participating in local, national and international safety programmes.
  • Learning was based on thorough analysis and an investigation into when things went wrong and when things went well.

Effectiveness was rated as outstanding because:

  • The policies seen were based on National Institute for Health and Care Excellence (NICE) and other relevant guidelines.
  • Staff participated in a wide range of clinical audits and were involved in research.
  • Care bundles and individualised care pathways were embedded in practice.
  • Patient outcomes were monitored and presented in the annual paediatric intensive care report, which included the international benchmark.
  • Staff received a structured induction with agreed development objectives, which were monitored with clear competencies developed by the education team within this service.
  • There was a holistic approach to assessing, planning and delivery of care delivered by the multidisciplinary team across this service.

Caring was rated as outstanding because:

  • The high dependency unit (HDU), Paediatric Intensive care Unit (PICU), supporting services including the post-acute care enablement (PACE) team and the transport team staff all demonstrated that they were fully committed to delivering high quality, individualised patient-centred care.
  • Children and their families were treated with compassion, dignity and respect. Parents stated they were positive about the care received by their children and felt involved and informed.

Responsive was rated as outstanding because:

  • The flow of children through PICU was managed effectively to avoid delays with discharges and manage capacity with the increased demands on this service. Safety huddles were held three times a day with extra huddles as demand necessitated.
  • The individual needs of the children were met with the use of individualised patient photographic folders with clear instructions relating to their individual position preferences.
  • Any delays with discharge were escalated at the earliest opportunity and the capacity managed with support from the hospital operational clinical site team.
  • Parents and families were supported during and after discharge from this service.

Well-led was rated as outstanding because:

  • This clinical service group had a vision and strategy for development of the service. All staff spoken to confirmed they were part of ‘team BCH’ and all staff knew the local vision.
  • Staff were able to raise concerns and were supported.
  • Leadership was visible and there was a keen sense of teamwork and a positive culture.
  • Research and implementation of findings was very strong with communication sheets contained within each patient family folder.
  • The staff worked well in engaging with the children and their families and external groups to seek feedback and support for the service.

End of life care

Outstanding

Updated 21 February 2017

During our inspection there were no patients at the hospital requiring end of life care, although there were some palliative care patients, therefore we have gained assurance from documents and interviews with staff.

Overall, we rated end of life care at Birmingham Children’s Hospital as outstanding, having safe, effective and well led as good.

  • There was a positive, transparent culture of incident reporting and learning from incidents. Sufficient numbers of appropriately qualified and trained staff were on duty to ensure patients were kept safe.

  • Staff used national guidelines and evidence-based treatment when looking after patients. The hospital took part in several national audits and staff were encouraged to carry out local audits. Results of audits were used to improve patients’ experiences and care.

  • Feedback from parents and patients about the care they received was consistently excellent. Parents, carers and patients we spoke with said staff “went the extra mile” and were “brilliant” or “excellent” and the care given was much more than they expected.

  • Patients and their families were treated with respect, dignity and compassion, particularly at the most difficult times, and bereaved parents were given genuine, compassionate care with clear emotional support if a child died. Staff displayed a great sense of pride in the end of life care provided at the hospital. Patients’ needs and those of families and other representatives of patients were considered throughout the process and following death. Parents were involved at every stage and were treated as individuals.

  • Patients were treated as individuals and different approaches were taken, when needed, to care for them in the most appropriate way. People from different cultures, backgrounds and religions were supported by staff and adjustments were made to accommodate their needs.

  • Leaders had an inspiring purpose and common focus to deliver the best possible care to the children in their care, and this attitude was shared by staff at all levels. Staff across all groups were proud of the organisation as a place to work and spoke highly of the culture. Many staff told us the hospital was “the best place they had ever worked” and said they “couldn’t imagine working anywhere else”.

Outpatients

Good

Updated 21 February 2017

We rated outpatient and diagnostic imaging services as good.

The safety and responsiveness of the service was good because:

  • There were clear processes for the reporting of incidents.

  • Staff were encouraged to report incidents using the electronic incident reporting system.

  • We observed staff using appropriate hand washing techniques and personal protective equipment, such as gloves and aprons whilst delivering care.

  • Care was provided at flexible times to increase the accessibility of the service being provided.

  • The trust involved the Young Person’s Advisory Group when planning the delivery of outpatient and diagnostic imaging services.

There was an outstanding level of caring across all outpatient and diagnostic imaging services because:

  • When speaking to children, parents and carers they were continually positive about the care that was provided and the way that staff treated them.

  • People told us and we saw that staff made an extra special effort when they provided care. Staff were committed to empowering young people through providing them with appropriate information and support to enable them to make decisions around the care they received.

  • Children, young people and their carers told us that they were treated with compassion, dignity and respect.

  • We saw numerous examples of staff going beyond the remits of their role to overcome obstacles to ensure the needs of the child, family and carers were met.

  • We found strong local leadership in outpatient departments.

However, we also found areas requiring improvement in the well led domain, relating mostly to diagnostic imaging services:

  • We observed and staff told us that radiographers and radiologists did not work as a cohesive team.

  • The on call system for radiographers was not in line with trust policy with regard to compensatory rest for staff called out during on call shifts.

  • The trust wide appointment scheduling system had not been fully implemented in radiology.

  • Clinical staff in outpatient departments were performing administrative tasks due to a lack of administrative and clerical support. We observed that this was adding to the delays experienced by patients in the ENT clinic.

Other CQC inspections of services

Community & mental health inspection reports for Birmingham Children's Hospital can be found at Birmingham Women's and Children's NHS Foundation Trust.