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Birmingham Heartlands Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 1 June 2015

Heart of England Foundation Trust is a large NHS provider of acute hospital and community services in Birmingham and Solihull. The hospitals are in the East and North of Birmingham and one smaller site in Solihull West Midlands. There is also the Birmingham Chest Clinic which is in the centre of Birmingham The trust has some community services in Solihull. We did not inspect the community services or the Chest Clinic. The three acute sites are Birmingham Heartlands Hospital, Good Hope Hospital and Solihull Hospital. Along with the community service the trust serves approximately 1.2m people. The Birmingham Heartlands site is where the trust headquarters are located.

We carried out this unannounced responsive inspection because the trust was in breach with regulators Monitor, and we had received intelligence which warranted our response and so we arranged the inspection. The inspection took place between 08 and 11 December 2014. We had inspected the service in November 2013 and the trust was still working through compliance action plans.

This inspection was an unannounced responsive inspection and as such we will not be rating the service. The purpose of the report is to share with the trust and the public the evidence we gathered during that inspection. It is also important to note that at the time the trust was in transition with many changes within the trust executive team, some of whom were in interim posts. This had been precipitated by the previous Chief Executive resigning in November 2014.

Our key findings were as follows:

  • Widespread learning from incidents needed to be improved.
  • Appraisals for staff were not widely undertaken achieving 28% compliance at the time of our inspection.
  • Staffing sickness and attrition rates were impacting negatively on existing staff.
  • The congestion within the hospital was having negative impacts across all the core areas we inspected. For instance the number of patients having to wait in recovery more than 30 minutes was high.
  • Discharge arrangements required improvement; we saw that only 35% of patients were discharged on or before their planned date of discharge.
  • The care of the deteriorating patient was generally managed well.
  • Arrangements for patients with reduced cognitive function were not always effective. This meant that some patients did not receive the level of care and support they required.
  • The leadership was in a transition phase with many in interim posts.
  • The culture within the trust was one of uncertainty due to the number of changes which had occurred.
  • Staff could not communicate the trust vision and strategy.
  • Governance arrangements needed to be strengthened to ensure more effective delivery.
  • IT reporting needed to be improved to ensure reporting was accurate.

We saw several areas of outstanding practice including:

  • On the Acute Medical Unit (AMU) at Birmingham Heartlands Hospital (BHH) local complaints resolution was very responsive to patient’s needs. The complainant was invited to a meeting and given a recording of the discussion. This appeared to resolve complaints quickly.
  • AMU, Ambulatory Care, wards 10, 11 and 24 provided excellent local leadership, services were well organised, responsive to patients individual needs and efficient which resulted in excellent patient outcomes.
  • The Practice Placement team provided excellent links between the trust and the University in supporting more than 600 student nurses across all three hospital sites.

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

  • BHH Emergency department appeared at crisis with overcrowding and lack of flow, leading to a high stress, high risk environment for both patients and staff.
  • Arrangements for patients who required mittens were not undertaken to maintain patient’s safeguards.

Importantly, the trust must:

  • The trust must take effective action to achieve consistent staff compliance of infection control procedures within the emergency department.
  • The trust must address the ambivalence held by staff about reporting incidents as they may be underreporting and trust could miss important trends.
  • The trust must ensure that staff are clear about clinical responsibility for patient’s awaiting handover by Ambulance services in the emergency department at Heartlands.
  • The trust must take effective action to address the crowding in the majors area of the ED department and ensure that staff on duty can see and treat patients in a timely way.
  • The trust must ensure all patients requiring items of restraint such as hand control padded mittens are supported with a mental capacity assessment, a DoLS and are regularly reviewed by the MDT which is recorded in the patient’s notes and mittens are replaced when soiled. A consistent practice must be adopted across the trust.
  • The trust must provide sufficient staff to operate the second obstetrics theatre at night, and prevent delays occurring.
  • The hospital must improve the information available to outpatients departments to ensure that these are monitored and action taken to improve services through audit, trending and learning.
  • The trust must take effective action to address the overcrowding in the majors area of the ED at Good Hope and ensure that staff on duty can see and treat patients in a timely way.
  • The trust must review the operation of rapid assessment of patients to improve its consistency and effectiveness.
  • The trust must ensure all fire doors and exits are free from clutter.

There were also areas of practice where the trust should take action, and these are identified in the report.

As a result of this, the trust will be subject to regulatory action as requirement notices and a comprehensive inspection will be carried out to confirm this.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 1 June 2015

Effective

Updated 14 January 2014

In general, we found that the services at Birmingham Heartlands Hospital were effective. Staff were beginning to see the effect of the recent recruitment programme, as new staff joined ward teams. The hospital managed its number of beds reasonably well to ensure that patients who needed a bed were given one. However, this sometimes had an impact on the availability of short-term beds for people undergoing surgical operations.

Caring

Updated 14 January 2014

Patients said that staff were caring despite being busy, and we saw some good examples of good care being delivered on the wards. In some areas, patients declared that the care was “exemplary” and were able to describe how staff had gone “the extra mile” to ensure that patients and their families felt cared for.

Responsive

Requires improvement

Updated 1 June 2015

Well-led

Requires improvement

Updated 1 June 2015

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 1 June 2015

Safer staffing information were not visible for women and visitors to the ward. The midwife to birth ratio was worse that the recommended average. Current arrangements for the cover of a second obstetrics theatre needed to be improved. The hospital did have an onsite consultant 24 hours a day, 7 days a week which was meeting national guidelines.

Staff involvement in future planning of service delivery was lacking. We also noted that facilities and specific arrangements for people with disabilities were not robust.

There was a lack of visible leadership and the staff were unclear about the maternity strategy and felt powerless to affect service development and delivery. Staff worked well in their teams, but there was little interdepartmental co-operation.

Medical care

Requires improvement

Updated 1 June 2015

Medical care (including older people’s care)

Requires improvement

Updated 2 August 2017

We rated the service overall as requires improvement because:

  • Nursing and medical vacancies were high and planned staffing levels were not always being met.

  • Infection control measures were not consistently applied and we saw poor levels of hand hygiene.

  • Patients experienced delayed discharges not only due to lack of care in the community, but to poor discharge management and arrangements. This included insufficient patient transport (operated by another provider) and porter provision.

  • There were a number of medical outliers: patients who were admitted to other wards as there was no appropriate medical bed free. Medical reviews of these patients were on some occasions being missed.

However:

  • The trust had a rolling recruitment drive both nationally and internationally and were recruiting with success.

Urgent and emergency services (A&E)

Requires improvement

Updated 2 August 2017

We rated this service overall as requires improvement;

  • When we carried out the inspection we found there were a number of safety issues. In particular the level of overcrowding and use of the corridors to house patients on trolleys.

  • There were risks around timely assessment and handover and the standard of care that staff were able to give because of this.

  • There were mixed levels of mandatory training and infection control measures.

  • Pain relief was poor for patients we received mixed feedback from patients and families.

  • There were significant issues with delays and flow of patients through the department.

  • There was poor morale amongst staff and little patient engagement.

However;

  • Staff training and education, stroke management, multidisciplinary working and working with other stakeholders was of a good standard.

  • Research was evident and results were used to inform improvement in care.

Surgery

Requires improvement

Updated 2 August 2017

We rated this service as requires improvement because:

  • BHH reported three never events from August 2015 to July 2016. Never Events are serious incidents that are wholly preventable as guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers. Two of these incidents related to procedures which were carried out on the wrong site of the patient’s body, indicating that learning from one incident did not take place in a timely manner.

  • Medicines were not stored safely and in line with requirements. We found some patient’s controlled medicines were past their expiry date, medicines which should have been protected from the light were not, and the temperature of the refrigerators used to store medicines exceeded recommended limits at times.

  • Patients with a fractured hip waited for up to 12 hours for their pressure relieving mattresses..

  • Patients experienced delays in their journey from admission to discharge. This included delays in returning from the operating theatres to the wards due to a lack of available beds on the surgical wards.

  • Delays in discharging patients occurred due to waits for medicines to take home (TTOs)

  • Services were not always responsive to the needs of individual patients and those who were vulnerable. Staff did not always use the trust’s translation service and instead used patients’ families and friends to interpret for them when discussing patient care. There was limited provision for patients living with dementia or a learning disability.

  • Governance structures were in place but were not fully embedded. Risks were not always identified and managed appropriately.

  • Staff described a blame culture when being held to account for incidents during root cause analysis (RCA) executive forum meetings.

However, we also saw:

  • There was a good incident reporting culture. Managers shared learning from incidents with staff through newsletters, ward meetings, handovers, between teams and staff notice boards.

Intensive/critical care

Good

Updated 2 August 2017

We rated this service as good because:

  • Staff were caring and compassionate.

  • There were sufficient and competent medical and nursing staff available to provide care and treatment for patients seven days a week. However the availability of other health professionals such as physiotherapists did not meet intensive care core standards.

  • The leadership, governance and culture of critical care services promoted the delivery of safe, high quality person-centred care.

However we also saw that:

  • The critical care units (ITU and HDU) did not meet the needs of a modern service. There were no toilet or bathroom facilities within either ITU and HDU.

  • Heartlands Hospital is a regional infection diseases centre. There were three side rooms within the intensive care unit (none within the high dependency unit), which could be used for critically ill infective patients. However, none had modern facilities (negative pressure to contain any bacteria within the room) to reduce the risk of, cross infection to other patients.

Services for children & young people

Good

Updated 14 January 2014

Children’s safeguarding procedures were robust and had been improved in response to findings from a serious case review. Assessments of patients’ needs were undertaken on admission by both nursing and medical staff, and care and treatment were delivered effectively by caring staff. There was a strong management presence in the form of the head of nursing, matron and supervisory ward sisters or managers. There was evidence of regular senior meetings and completion of audits to monitor the quality of service provided. There was also evidence of learning and improving as a result of incidents that had occurred. However, the hospital was not responsive to the management of children and adolescents or young people with mental health needs. This was because staff had received no mental health training, and there were no policies (other than one for suicidal patients) or pathways in place to ensure consistency in practice. Risk assessments were undertaken but were not robust enough to minimise the potential risks to these patients.

End of life care

Good

Updated 14 January 2014

Patients received safe end of life care. They had support to make decisions about their care and staff working in the service were experienced, knowledgeable and passionate about providing good care outcomes for patients. Patients and their families had positive views about the end of life service. The hospital had worked hard to meet the needs of its local ethnic population and to ensure that the religious and cultural needs of people at the end of their life were met in a timely and sensitive way.

Outpatients

Good

Updated 2 August 2017

We rated this service as good because:

  • Staff were encouraged to report incidents of all kinds and all staff we spoke with were aware of how to do so.

  • Staff demonstrated good knowledge and understanding of safeguarding and were able to give recent examples of how they had followed protocols.

  • The departments were clean and logs showed that they were regularly cleaned and checked.

  • Medicines were stored appropriately and checks of controlled drugs completed daily.

  • Patient records were clear, legible, up to date and available for clinics.

  • We saw evidence of strong multidisciplinary working across departments, divisions and grades of staff.

  • Policies and protocols were based upon national guidance and reviewed and updated appropriately.

  • The World Health Organisation (WHO) checklist was used and practice seemed to be embedded.

  • We saw effective pain relief used for patients receiving treatment.

  • Staff told us they had effective access to information that enabled them to provide care and treatment to patients.

  • We saw that staff provided compassionate care for patients and respected the privacy and dignity of those attending the departments.

  • Patients and their family members or carers were fully involved in planning and choosing their care and treatment.

  • Patients gave positive feedback about the staff as being supportive and caring.

  • The breast clinic offered a ‘one stop’ service which patients could access quickly and receive results and treatment if possible on the same day.

  • Clinics ran during the evenings and weekends which gave patients choice of appointments and was working to reduce waiting times.

  • Staff displayed the trust values and understood what these were.

  • We saw and staff described that in most areas of the departments there was strong leadership in place and senior managers felt well supported by the executive team also.

However:

  • Patient records were left out on open trolleys which meant they were accessible and visible for other patients to see so did not ensure confidentiality was being maintained.

  • A piece of equipment in the ophthalmology department was three months overdue for servicing. This machine was still in use and therefore could be unsafe for patients.

  • Staff told us that clinics were often overbooked, appointments were often not long enough for patients and so clinics would over run and be held later that arranged. This impacted upon patients waiting times and staff had concerns that appointments may seem rushed.

  • The controlled drugs documentation in the ophthalmology department indicated that use of these was not always witnessed and/or signed out appropriately.