University Hospitals Birmingham NHS Foundation Trust

Updated 8 March 2024

University Hospitals Birmingham NHS Foundation Trust is one of the largest teaching hospital trusts in England, serving a regional, national and international population. It includes running four major hospitals: Birmingham Heartlands Hospital, the Queen Elizabeth Hospital Birmingham, Solihull Hospital, and Good Hope Hospital. It also runs a number of community services, including the Birmingham Chest Clinic, the Norman Power Centre and the Washwood Heath Community Diagnostic Centre.

The trust sees and treats more than 2.2 million people every year and employs around 24,600 members of staff.

The trust is a regional centre for cancer, trauma, renal dialysis, burns and plastics, HIV and AIDS, as well as respiratory conditions like cystic fibrosis. It also provides services in premature baby care, bone marrow transplants and thoracic surgery and has the largest solid organ transplantation programme in Europe. It also provides specialist cardiac, liver and neurosurgery services to patients from across the UK.

The Queen Elizabeth Hospital Birmingham has been designated both a level 1 trauma centre and host of the UK’s National Institute for Health Research (NIHR) Surgical Reconstruction and Microbiology Research Centre (SRMRC).

This was a trust which had been through a period of substantial change in recent years. This has included the merger (by acquisition) in 2018 of two large NHS Birmingham-based trusts to form University Hospitals Birmingham NHS Foundation Trust. A new Chief Executive Officer took the interim role in January 2023 and was confirmed into post in July 2023. Other executives have left the organisation this year, or will leave in the course of 2023. There is therefore a relatively new and changing board of directors and a number of the non-executive directors are recent appointments. A new Chief Operating Officer has been appointed but not yet taken up their post. A couple of the long-standing non-executive directors are coming to the end of their term, so more new appointments are expected. The Chief Medical Officer will step down from their role to take up a nephrology and research role in the trust later in 2023 and recruitment was underway for their replacement.

To add to these changes, the trust is at the beginning of a major transformation of its operating model. The trust board recognised that the governance of a trust of this size being based around seven cross-cutting divisional structures needed to be revised. The trust is now in the early stages of the new structure, rolled out in phase one at the start of October 2023. This will place the responsibility for local governance, quality and safety with a hospital-based leadership model. Each hospital will have its own senior leadership team, led by an executive director. These teams will have devolved responsibilities from the main trust board (to be known as the ‘group’ board) to run and manage most clinical services at site level. Some teams will remain reporting through to the group board and not devolved to hospital level with some services remaining on a shared-service basis such as pharmacy and pathology.

The trust has been subject to some intense media scrutiny in the past couple of years, mostly around areas of culture, bullying and harassment. This culminated in the recent publication (September 2023) of a culture review by an external company commissioned by the trust chair.

The trust has undergone an extensive capital investment programme including seven new hospital wards, a new cardiology daycase unit at Good Hope Hospital, and a treatment centre at Heartlands Hospital for 1,500 patients to be treated every day. It has opened an improved treatment centre in Solihull and a diagnostic centre in Washwood Heath, due to open in January 2024.

Our inspection in August and October 2023 included a focused review of critical care services at the Queen Elizabeth Hospital Birmingham, and a focused review of well-led. Critical care was limited to the key lines of enquiry around safety and leadership (well-led). Our well-led inspection focused on four of our key lines of enquiry, namely leadership; culture; governance; and management of risk, issues and performance. We recognise the trust would have provided evidence of groundbreaking and innovative care and treatment had we explored our other key lines of enquiry. However, this review was limited to these four specific areas following serious concerns raised by stakeholders and recent culture reports.

We carried out core-service inspections between February and July 2023 in maternity services, urgent and emergency care, medical care, and two focused inspections of specialist services (cancer and neurological services). In these inspections we rated as follows:

At the Queen Elizabeth Hospital Birmingham we inspected and rated:

• Urgent and emergency care rated as requires improvement overall with an inadequate rating for safe. Effective, responsive and well-led were requires improvement and caring was good.
• Neurological services rated as requires improvement overall with an inadequate rating for well-led. Safe, effective and responsive were requires improvement, and caring was good.
• Cancer services (focused inspection) rated as require improvement overall. We inspected safe and well-led, both of which were rated as requires improvement.
• Critical care (focused inspection) rated as requires improvement overall. We inspected safe and well-led, both of which were rated as requires improvement.

At Birmingham Heartlands Hospital:

• Urgent and emergency care rated as requires improvement overall (revised from an inadequate rating) with an inadequate rating remaining for safe. Effective, responsive and well-led were requires improvement and caring was good (improved from requires improvement).
• Maternity services (focused inspection) rated as inadequate overall. This was a follow-up inspection from a warning notice served and did not change the ratings.

At Good Hope Hospital:

• Urgent and emergency care rated as inadequate overall with inadequate ratings for safe and well-led. Effective, caring and responsive were requires improvement.
• Medical care (focused inspection) rated as inadequate overall with inadequate ratings for safety and well-led. Well-led was revised from requires improvement to inadequate at this inspection.

During our focused well-led inspection, we spoke with many of the trust executive directors, almost all of the non-executive directors, in a group call, and held focus groups and interviews with staff and network leaders. A number of staff contacted us both prior to, during and after the inspection with information of concern. However, despite this inspection being announced several weeks in advance, we were disappointed with the number of staff who chose to come and meet with us, either face-to-face or on a web-based call. We were told by the staff we did meet, that many of their colleagues were not aware of the meetings or they had been unable to join due to it clashing with other responsibilities. A number of staff also told us they did not have access to computers or an office where they could have a private conversation. Nevertheless, we recognised staff were busy, may have been unable to make one of the limited times on offer, and we were also only available face-to-face on one site due to time and resource pressures.

How we carried out the inspection

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection

Updated 13 February 2019

This is the first inspection of this service. We rated it as requires improvement because:

• Staff had not recognised or reported incidents which meant appropriate investigation and learning had not been undertaken.
• Robust arrangements were not in place for administration of non-prescription and as required medicines.
• Essential equipment to weigh children and young people was not available.
• Whilst most of services had sufficient staff, long term staff absence within the learning disability nursing service had impacted adversely on children’s access to care and treatment.
• There was a need to ensure transition arrangements between children’s and adults services met best practice.
• The referral to treatment wait for the special assessment service, autism service and occupational therapy service had consistently exceeded the required waiting time and were not in line with good practice.
• There was a need for greater insight and engagement from more senior managers within the trust to ensure safe, high-quality and sustainable service was provided.
• Arrangements for governance and performance management did not always operate effectively.

However:

• Staff went beyond expectations to treat children, young people and their loved ones with kindness and compassion.
• Children, young people, and their loved ones were active partners in their or their children’s care.
• The service provided mandatory training in key skills for staff and most staff had completed it.
• The service monitored the effectiveness of care and treatment and used the findings to improve them.
• Staff understood how to protect patients from abuse and had training on how to recognise and report abuse and they knew how to apply it.
• Staff had the qualifications, skills and experience and ongoing training and their competence was monitored appropriately.
• There was effective multidisciplinary working to provide high quality and effective care.
• The service was responsive to the individual needs of children, young people and their families.
• The service and its staff were committed to improving and developing services and learning when things go well.

Updated 13 February 2019

For this inspection, we rated end of life care services as Good for safe, caring and responsive. We rated the service as Requires Improvement for effective and well led.

Overall, we rated the service as requires improvement because:

• Patient outcomes were not regularly monitored and reviewed to ensure the end of life care service was meeting the needs of patients.
• There were no audits to identify the ratio of cancer to non-cancer patients treated by the service.
• The service did not monitor or audit patients preferred place of care or death. However, they did provide a rapid response team to support patients to be discharged.
• Two of the five of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders we viewed were not completed correctly as they did not include a mental capacity assessment, despite stating the patient ‘lacked capacity’. We were therefore not assured that the Mental Capacity Act legal requirements were always implemented for people who had DNACPR orders.
• There was no end of life care strategy for community end of life care services.
• The trust did not have a specific strategy for end of life care which incorporated planning to meet the needs of the local population.
• The trust did not have a service improvement lead for community end of life care services.
• There was no end of life care regional steering group.

However:

• Staff had a good understanding of how to protect patients from abuse and could describe what safeguarding was and the process to refer alerts.

• Overall, we found the standards of cleanliness and hygiene were good and staff demonstrated a good knowledge of procedures for the management, storage and disposal of clinical waste, environmental cleanliness and the prevention of healthcare acquired infection.

• Comprehensive risk assessments were carried out for patients and risk management plans

developed in line with national guidance.

• We saw good examples of good multi-disciplinary working and involvement of other agencies and support services.

• From to , the trust reported no never events in community health services for end of life care.

• All patients, their relatives and care givers told us they were fully included in discussions around their plan of care.

• There were systems in place to ensure that staff affected by the experience of caring for patient at end of life were supported. For example, members of the SPCT had access to a clinical psychologist based at the local hospice, through a self-referral system as well as a psychologist who provided clinical supervision to individuals or groups, as required.