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Inspection Summary


Overall summary & rating

Requires improvement

Updated 31 October 2017

City Hospital (formerly Dudley Road Hospital, and still commonly referred to as such) is a major hospital located in Birmingham, England, operated by the Sandwell and West Birmingham Hospitals NHS Trust, Serving a population of around half a million people.

It provides an extensive range of general and specialist hospital services. It is located in the Winson Green area of the west of the City. On the City site, there is also a Birmingham Treatment Centre (BTC) and a Birmingham Midland Eye Centre (BMEC).

We carried out an unannounced visit on the Medical Core service in February 16, 2017, followed by a short notice announced inspection in March 28-30, 2017, with another unannounced visit in April 6, 11-13 2017.

We have made judgements about six core services within City Hospital and rated each one individually.

Our key findings were as follows:

  • Incident reporting and shared learning needed to be improved across the organisation.
  • The trust held 10 quality improvement half days (QIHD) per year during which time staff shared learning and attended relevant training.
  • Robust application of the World Health Organisation’s (WHO) ‘five steps to safer surgery’ checklist was visually monitored on a daily basis.
  • The trust had made a vast improvement in the end of life care service since 2014 inspection.
  • We saw examples of positive multi-disciplinary working and staff told us this was consistently good across the trust.
  • Infection control had improved since the inspection in 2014, however, this varied across both sites. Mortuary staff were not following the trust’s infection control policy. We were not assured the service was protecting mortuary staff and the general public that visited the mortuary from potential health and infection risks, infection control training was not included in the mortuary mandatory training.

We saw several areas of outstanding practice including:

End Of Life Care:

  • The palliative and end of life care service integrated coordination hub, acted as one single point of access for patients and health professionals to coordinate end of life services for patients.
  • The service provided access to care and treatment in both acute hospitals and in the community, seven days a week, 24 hours a day.

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

Importantly, the trust must:

BMEC-Emergency Department

  • Increase availability of specialist medical staff and anaesthetists to minimise the risk that children, particularly those younger than three years of age, who attended department receive timely and appropriate treatment.
  • Robust policies and procedures are in place to manage the effective security of prescription forms at a local level.
  • The storage of fluids are tamper proof, in line with Resuscitation Council guidelines.
  • Patient records must meet standards for general medical record keeping by physicians in hospital practice.

Medicine:

  • Ensure compliance with the Mental Capacity Act (2005) is documented.
  • Ensure attendance at mandatory training is improved.
  • Take steps to reduce delays in the patient journey and ensure people are able to access care and treatment in a timely way.
  • Improve the consistency of multi-disciplinary processes and ensure the implementation of consultant led board and ward rounds.
  • Ensure patients have access to translation services when required.
  • Ensure governance structures are embedded and a structured approach is taken to the identification and management of organisational risk.

Surgery including BMEC:

  • Ensure measures are in place to prevent further Never Events to protect patient’s safety.
  • BMEC mandatory training targets for all clinical staff are met and recorded.

Children and Young People BMEC:

  • Improve local governance and ensure risks to the service are escalated, recorded, acted upon and reviewed in a timely manner.
  • Medical staffing meets needs of patients and the service.
  • Review the storage of emergency drugs and equipment for children and young people
  • Age appropriate facilities are provided with separation of adult and children waiting areas and treatment areas.
  • Mandatory training targets are met and recorded including paediatric life support.
  • A framework for staff to develop and demonstrate competencies to care for children is in place.

Outpatient Department including BMEC:

  • Resuscitation trolleys are locked and secured with tamperproof tags.
  • Patient notes are kept securely and confidentially.
  • Sharps bins and clinical waste are stored securely and safely.
  • Consulting rooms in BMEC protect patients’ dignity and privacy, and prevent people from overhearing conversations between staff and patients.
  • There are improvements with staff completion of mandatory training.
  • All staff that carry out root cause analyses are trained to do so.
  • The consulting rooms in the BMEC orthoptics department were large, and two or three patients underwent consultations at the same time, only separated by screens. Patients were able to overhear conversations between staff and other patients in the room. Staff told us they were not able to protect patients’ dignity and privacy due to the way the rooms were set up, but they had one single room they were able to use if patients expressed concern. We asked staff if they told patients about this facility and if staff offered it to patients for their consultation; Staff told us that the patients only used the room if they raised the issue

In addition the trust should:

Urgent and Emergency care including BMEC:

  • The trust should review cleaning schedules and include the windows above the minors’ area, which were not part of the housekeeping schedule and had not been cleaned for several months.

  • The trust should review action plans from national and local audits, in particular record keeping audits to improve the quality of patient records.

  • The trust should improve the communication of waiting times to patients, especially if electronic displays are not in use.

  • Look for ways to improve patient privacy in the department.
  • Improve the waiting area and provision of age appropriate toys and games for children and young people in the department.
  • Consider introducing an electronic flagging system for vulnerable patients, such as those living with dementia or a learning disability.
  • Consider participating in a wider range local and national audits in order to assess, evaluate and improve care of patients in a systematic way
  • Staff should routinely assess patients’ pain on arrival to the department.
  • Introduce a water dispenser in the BMEC ED waiting room to ensure vulnerable patients have quick access to water at all times.
  • Implement SLA’s with other trusts so that paediatric patients are kept safe at all times
  • Improve communication from executive colleagues regarding changes being proposed to the department.

Medicine:

  • Review the content of the emergency resuscitation trolleys and ensure security of the contents.

Surgery including BMEC:

  • Safety thermometer information should be displayed on the wards. Staff members should be aware of their ward scores.
  • Competencies for nursing staff working in surgical specialisms should be revisited after their initial competency ‘sign off’ stage.
  • Patients should be consented for surgery prior to arrival on the ward
  • Wider learning should be promoted through complaint trends being shared amongst all areas of the trust
  • Ensure all BMEC staff are aware of the duty of candour and when this would be applied, following a notifiable safety incident.
  • Ensure all BMEC staff can identify a deteriorating patient; and that this is recorded in a structured way in order to monitor the effectiveness of this.
  • BMEC service work towards minimising cancelled procedures due to lack of patient records.
  • BMEC staff to be fully aware of when patients may require a deprivation of liberty safeguard (DOLS) application in order to ensure patients that lack capacity to consent to treatment is provided with appropriate care.

Children’s and Young People BMEC:

  • That a strategy for services for children and young people is developed and embedded, and there is improved reporting about service plans and priorities.
  • Review the arrangements for data collection that is specific to children and young people such as the audit plan and reporting, training and development records.
  • Greater visibility and support of the children and young people service from the executive leadership team.

End Of Life care:

  • The service must ensure they are preventing, detecting and controlling the spread of infections, including those that are health care associated in the mortuary department.
  • The trust should ensure they have updated ‘Anticipatory Medication Guidelines’. We could not be assured staff were following the most up-to-date guidelines.

Outpatient Department including BMEC:

  • Staff working in the outpatients department have their competencies checked regularly and that this is evidenced.
  • Ensure that staff receive training to improve awareness of who the trust safeguarding leads are.
  • The layout of the consulting rooms in the BMEC orthoptics department did not always ensure patient’s privacy and dignity were protected.
  • Ensure all incidents are reported including those involving patient falls on the escalator in the Birmingham Treatment Centre.
  • Patients in the BMEC outpatients waiting area are kept informed of waiting times and late-running clinics.
  • Reassess the layout of the BMEC coffee shop seating area to ensure people can move about safely, and sufficient space is provided for people using wheelchairs.
  • All staff have annual appraisals.
  • There are chaperone notices in the outpatient’s department.
  • There is clear signage in the outpatient’s department.
  • Staff complete training to raise awareness and improve skills for working with people with learning disabilities.

Ted Baker

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 31 October 2017

Effective

Requires improvement

Updated 31 October 2017

Caring

Good

Updated 31 October 2017

Responsive

Requires improvement

Updated 31 October 2017

Well-led

Requires improvement

Updated 31 October 2017

Checks on specific services

Maternity and gynaecology

Good

Updated 26 March 2015

Overall we rated the maternity services as good. The service was effective, responsive, caring and well-led.

The service provided effective care and treatment that followed national clinical guidelines and staff used care pathways as required.

Staff were caring towards women and treated them with dignity and respect. Systems were in place for women to receive on going physical and emotional support throughout their pregnancy as they required. Staff had a good understanding of the need to ensure vulnerable people were safeguarded.

The trust had also introduced significant changes in response to audits which showed that a lot of babies were being readmitted to hospital.

Leadership of the maternity service was visible and promoted innovation and positive change.

Medical care (including older people’s care)

Requires improvement

Updated 31 October 2017

We rated medical care as Requires Improvement because:

  • Medical services were one of the areas of most concern at the trust and had been so for the past two years. Although there had been significant improvements across this service since the last inspection, progress was slow.
  • We found a range of concerns in relation to the safety of care including the prescribing of medicines and low staff attendance at some mandatory training such as basic life support training.
  • There was limited learning from incidents and safety concerns were not always addressed promptly. We found this in relation to infection prevention and control, the contents of emergency resuscitation trolleys and the management of patients living with dementia.
  • There was inconsistency in the application of the Mental Capacity Act (2005) when people were unable to make some decisions for themselves. Decisions about people’s care had been made without evidence of mental capacity assessments being completed or evidence of how decisions were made in their best interests. Deprivation of Liberty Safeguard (DoLS) applications which are required to provide authorisation for a person’s freedom to be restricted to maintain their safety, did not always contain the information required to ensure the safeguards were being applied appropriately and in the person’s best interests.
  • There were variations in the quality of management and leadership, leading to a lack of consistency in care processes and which impacted on the effectiveness and responsiveness of care.
  • Delays occurred at most stages of the patient journey from admission to discharge.

However:

  • The service took account of the needs of vulnerable patient groups including those with a learning disability and those who were unable to speak English. Adaptations had been made to the environment to better meet the needs of patients living with dementia and an activities coordinator provided therapeutic activities for those living with dementia or with delirium and those without outside contacts.
  • The outcomes for patients undergoing care for specific medical conditions were measured and compared with other trusts through participation in national clinical audits. The outcomes for patients with heart failure and following heart attacks were in line with or better than the national average.
  • There were some improvements in key performance indicators relating to the quality and safety of care. Managers were aware of the issues in relation to the consistency of care and an improvement programme to reduce delays in the patient journey from admission to discharge was underway.

Urgent and emergency services (A&E)

Requires improvement

Updated 31 October 2017

  

We rated ED as requires improvement because:

  • The overall quality of patient notes at City Hospital ED was variable, with adult notes being less consistent.

    Patient records at BMEC ED did not meet standards for general medical record keeping by physicians in hospital practice

  • Staff told us that the rotation of staff between sites was not liked and that they were not comfortable when working at the Sandwell hospital.

  • Between December 2015 and November 2016, the trust’s unplanned re-attendance across both sites was worse than the England average.

  • Information for the trust from February 2017 shows that 82% of patients spent less than 4 hours in the ED, which is below the national average of 85.5%.

  • There was a lack of consistent management across the two main sites.

However,

  • Staff told us that they were encouraged to report incidents and the incident reporting culture had improved at City ED from the last inspection in 2014.

  • We found that the system for storing and controlling medicines in City Hospital ED had improved since the last inspection.

  • We saw patients being cared for with compassion and staff were considerate to patient needs.

  • Multi-disciplinary team worked well together. Medical and nursing staff worked well with each other and communication with other specialities was good.

  • The children’s ED was adjacent to the main ED and separated visually and audibly to ensure better privacy and safety.

  • Local leadership was good and we saw the manager available to staff for support.

  • The paediatric emergency medicine (PEM) consultant was creating learning opportunities for staff, introducing a consistent approach to work within children’s’ ED.

  • We saw a good culture of hand washing and using hand sanitising gel. Staff and visitors were observed using the hand sanitising gel appropriately.

Surgery

Good

Updated 31 October 2017

We rated surgery services as Good because:

  • The trust held 10 quality improvement half days (QIHD) per year during which time staff shared learning and attended relevant training.

  • Robust application of the World Health Organisation’s (WHO) ‘five steps to safer surgery’ checklist was visually monitored on a daily basis.

  • Staff were aware of Duty of Candour and their role when things went wrong; they had an understanding of the Mental Capacity Act 2005.

  • Staff were seen adhering to the infection control policy of arms bare below the elbow. The use of hand sanitiser and protective clothing policy was also adhered to.

  • Theatres and the wards were clean and tidy; cleaning schedules were dated, signed and displayed.

  • Medication refrigerators temperatures were recorded daily and medication cupboards were locked.

  • We saw that patients’ medical records were secure in all areas.

  • Staff were aware of how to report safeguarding concerns and what to look for when caring for patients.

  • Mandatory training and appraisal rates were variable but on target to be met.

  • A dependency ‘acuity tool’ was used to assess the staffing numbers required.

  • Bank and agency staff filled nursing staff vacancies.

  • Medical staffing was stable and locum cover was arranged as required.

  • Venous Thromboembolism(VTE) assessments were completed in line with national guidance and individual risk assessments were completed and audited.

  • Pre-operative assessments were completed to ensure patients were safe for surgery.

  • Multidisciplinary teams worked well together.

  • Staff were seen attending to call bells promptly.

  • Patients we spoke with told us they had received good cared from friendly staff. They were satisfied that their pain control had been managed well.

  • The average length of stay was below the England average for elective and non-elective surgery

  • Submission to the National 'bowel cancer audit' performance was recorded as 100% in 2016.

  • The trust’s referral to treatment time (RTT) for admitted pathways for surgery, was slightly above the England average, for overall performance since January 2016.

  • Local senior leadership was supportive and visible.

  • Patients and local people were encouraged to get involved in the hospital.

However:

  • Never Events had been reported, however robust measures had been taken to ensure patients safety in the future.

  • Safety thermometer information was recorded but not displayed on the wards.

  • Staff did not hear about other wards complaints so wider learning was not shared.

  • Staff felt listened to when they raised issues, but were less positive about the follow up action taken. Staff felt they were not being included in plans for surgical services.

Intensive/critical care

Good

Updated 26 March 2015

There were effective processes in place to learn from incidents. There were sufficient numbers of nursing and medical staff on duty. Medicines, including controlled drugs, were safely and securely stored.

We found there was good multidisciplinary team working across the unit.

There was strong medical and nursing leadership within the critical care unit. Staff felt well supported within an open, positive culture.

Services for children & young people

Requires improvement

Updated 31 October 2017

We rated this service as Requires Improvement because;

  • Children’s and young peoples’ services were delivered in a predominantly adult environment. There were no separate children and young people waiting areas, designated play areas, or children’s toilets in the day surgery unit (DSU) emergency department, or outpatients’ department.
  • Staff, including the leadership team, were unclear about the immediate plans, strategy, and priorities for the children and young people service.

  • Staff told us they would like to see greater recognition and support of the children and young people service from the executive leadership team. They described a lack of formal interaction with the trust board. Staff felt the executive team had not been visible and could not recall when they had last visited the service. However, staff told us there had been some recent improvement with increased engagement with medical staff, particularly consultants.
  • Medical staffing levels fell below national standards, particularly consultant staffing. There was no seven day cover from a consultant paediatrician and no agreed plans to increase the number of paediatric ophthalmology consultants.

  • There is a risk that children, particularly those younger than three years of age, who attend the emergency department at the Birmingham Midland Eye Centre with an emergency eye condition, do not receive either timely or appropriate treatment due to limited availability of specialist medical staff and anaesthetists.

  • There was no separate storage of adult and children and young people emergency medicines and equipment.
  • Surgical lists for children and young people were scheduled on Mondays and Thursdays only. The non-surgical service did not run at evenings or weekends, which reduced accessibility.
  • There was no evidence to demonstrate that staff had completed paediatric life support training, with the exception of three children’s trained nurses and one paediatric anaesthetist we spoke with. The leadership team identified their highest risk was there was no guarantee there would be a paediatric anaesthetist available for out of hours cases, or emergency cases, or for days when elective surgery was not taking place.

  • Children and young people friends and family test results, were not reported separately, this meant that there was limited opportunity to act on patient feedback to improve or change the service.
  • In the Birmingham Midland Eye Centre emergency department, we saw people overheard consultations with other patients due to the open plan layout.
  • Risks to the service were not always mitigated or acted upon in a timely manner and largely remained unresolved.
  • The trust did not provide or report on separate mandatory training for the children and young people’s service as it was part of the (adult) ophthalmology service within the surgical directorate. This has therefore been reported in the surgery, core service report.

However,

  • Nursing staffing levels in the DSU met the Royal College of Nursing (2013) Standards for Staffing Levels in Children and Young People’s Services.

  • The environment was clean, infection rates were low, and staff complied with infection prevention and control practices including hand hygiene and arms bare below the elbow.
  • The service had effective systems in place to ensure the safe supply, storage and administration of medicines.
  • Records were securely stored and maintained in in accordance with national and local standards.
  • Staff used an age specific paediatric early warning system (PEWS) to observe for clinical deterioration and appropriate action was taken as a result of the findings.
  • In the operating theatre, there was a dedicated recovery area for children and young people separated by screens from the area used by adults.
  • A recently introduced one stop pre-operative clinic helped to reduce the number of hospital appointments patients needed to attend.
  • Extended role training was underway to manage a range of new and follow up patients in allied health professional led clinics. This was designed to deal with the high volume of patients.
  • There was access to a multi professional health care team within Birmingham Midland Eye Centre who worked collaboratively to understand and meet the range and complexity of children and young people’s needs.
  • Interactions between staff and patients were individualised, caring and compassionate and children and young people and parents felt they were treated with dignity and respect.
  • Staff understood the trust safeguarding policy and had access to a named safeguarding lead nurse. Staff were provided with mandatory safeguarding training at a level appropriate to their job role.
  • Parents were involved in their child’s care and treatment. We saw staff spoke with children and young people in a way that enabled them to gain a full understanding of their treatment plan and take an active role in decision making.
  • Staff told us nursing and orthoptist leaders were supportive, visible and accessible.
  • The orthoptist team had introduced a formalised audit programme, and were working towards the introduction of allied health professional led clinics.
  • Staff attended monthly quality improvement half days, which addressed areas that required improvement, and encouraged reflection on how clinical delivery could be improved.
  • During our inspection, staff told us they felt there had been some improvements in engagement between medical consultants and the executive management team within the previous month, since the new team had taken up post.

End of life care

Outstanding

Updated 31 October 2017

We rated End of Life Care as outstanding because:

  • The palliative and end of life care service was tailored to meet the needs of end of life patients. Advice was managed and timely to take into account patient’s individual needs, including for patients with urgent needs.

  • The palliative and end of life care service worked together with commissioners and other providers to plan new ways of meeting people’s needs. The service had a strong focus on innovative approaches of providing integrated care pathways, particularly for patients with complex or multiple needs.

  • Patient admission, discharge and moving patients between hospital care and care in the community followed models of best practice in integrated, person-centred care.

  • The palliative and end of life care service designed services to meet the needs of the local community to enable all people to access palliative and end of life care services.

  • Patients had seamless access to palliative and end of life care, support and advice 24 hours a day, seven days a week.

  • Experienced staff provided a compassionate and responsive evidence based service for end of life care patients.

  • Incidents for the palliative and end of life care service were low. Staff were knowledgeable about the trust’s incident reporting process. We saw concerns were investigated thoroughly and learning widely shared.

  • The service had one single point of access for patients and health professionals to coordinate end of life care services for patients.

  • The palliative and end of life care service was well developed across the trust and held in high regard by all of the wards we visited.

  • End of life and palliative care was a priority for the trust. The service was well developed, staffed and managed as part of the iCares directorate within the Community & Therapies clinical group.

  • There was a clear governance structure from ward and department level up to board level.

  • Good governance was a high priority for the service and was monitored at regular governance meetings.

  • Staff were proud of their service, and spoke highly about their roles and responsibilities, to provide high levels of care to end of life patients.

  • We saw this often exceeded patient’s medical needs. We were told of numerous examples where the staff had gone the extra mile. This included arranging a wedding for a person in their last few days of their life to marry their long term partner. Staff had decorated the ward to make the event as special as possible.

  • Advanced care plans and specialised care plans were used across the trust for end of life patients. They were used as a person centred individual care record to include all the needs and wishes of a patient and their family.

  • The trust used a Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) form. The trust DNACPR was easily identifiable with a red border and was stored at the front of the patient notes. We saw all DNACPR forms were completed accurately on the wards. This was much improved from concerns raised during our last CQC inspection in October 2014.

However;

  • We saw mortuary staff were not following the trust’s infection control policy. We were not assured the service was protecting mortuary staff and the general public that visited the mortuary from potential health and infection risks.

  • Mandatory training for mortuary staff did not include infection control training.

Outpatients

Good

Updated 31 October 2017

We rated this service as good because:

  • We saw that staff reported the majority incidents of all levels and staff we spoke with were clear of the policies and procedures around this.
  • We saw that all areas were visibly clean and tidy and that there were processes in place to ensure these standards were maintained.
  • We saw that equipment was risk assessed and tested to ensure all risks were minimised
  • We saw examples of positive multi-disciplinary working and staff told us this was consistently good across the trust.
  • Policies and guidelines used were up to date, relevant and staff had access to them.
  • In the imaging department, local Diagnostic Reference Levels (DRLs) had been established, were reviewed regularly and reduced by the medical physics service whenever possible. We saw evidence that DRLs were discussed in IRMER committee meetings and we saw that mostly these were better than the national average.
  • We saw staff fully explain the process for assessment, examination and diagnosis and treatment in a clear way for the patient to understand. Patients we spoke with told us they had felt fully involved throughout their consultations and treatment.
  • We saw examples of innovation that would improve patient experience.
  • Extra clinics took place throughout the day and during the evenings to meet the demand of services and to reduce waiting times for patients.
  • The BMEC waiting area and processes for appointments had certain adaptions in place to meet the needs of patients using this specialist building. This included colour coded waiting areas, one-stop clinics, induction loops for the hearing impaired and a designated car park.
  • Staff told us that their local managers were supportive and worked with them towards improving care for patients. All of the staff we spoke with told us they felt they could raise issues with senior staff if they needed to.

However:

  • From April 2016 to March 2017, one ‘never event’ had been recorded at BMEC.
  • We saw that some rooms containing sharps bins were left unlocked and were therefore accessible for the public. We also saw some items that should have been stored under the Control of Substances Hazardous to Health (COSHH) were in unlocked cupboards.
  • Resuscitation trolleys were left open in patient areas and did not have tamperproof tags.
  • Staff told us about frequent incidents involving the escalator in the Birmingham Treatment Centre. The data provided did not reflect the amount of incidents that the staff told us occurred, therefore we had concerns that not all incidents were reported with regards to the escalator.
  • We saw that patient records were at times left on trolleys or desks unattended. This meant that staff were not always protecting patient confidentiality.
  • Staff in the outpatients department did not have their competencies regularly assessed to ensure they were confident and competent to carry out their role.
  • The layout of the consulting rooms in the BMEC orthoptics department did not always ensure patient’s privacy and dignity were protected.
  • There were no chaperone notices in any of the outpatient areas.
  • Staff told us that clinics often went over the scheduled time and patients could therefore be waiting longer than expected.
  • There had been a workforce review of staffing for the service across all OPD services, which had led to significant changes in the two years prior to the inspection. Staff told us they had not felt part of this and that they felt unaware of the strategy for the future of the service.