Acorns Children's Hospice in Birmingham

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm. There was a positive and proactive culture around safety, patients were protected from the risk of bullying, harassment, abuse, discrimination and avoidable harm and neglect. Staffing levels ensured the service met the needs of people; staff understood risk factors and managed them well. They ensured people were protected from the risk of infection. Medicines were managed in a safe way which met people’s needs, and the service were modernising the location to ensure people were cared for in a safe environment.

This service scored 81 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Safety was a top priority that involved everyone. All staff knew what incidents to report and how to report them. Staff raised concerns and reported incidents and near misses in line with the services policy. Staff spoke confidently about the incident reporting policy and what incidents to report. The service were preparing to implement the Patient Safety Incident Response Framework which would replace their current incident reporting method.

Data from the service showed there were 73 incidents reported between January and July 2025. The majority of these incidents were graded no harm incidents (46 incidents). The most common related theme of incidents was in relation to medication. There were no never events or incidents reported as serious harm reported during this time.

There was a culture of openness, transparency and learning. Staff understood the formal duty of candour process and implemented this when required. Staff prided themselves on their general openness and transparency and if things went wrong, would apologise and provide a full explanation.

Lessons were learnt from safety incidents raised. Staff were able to share examples of learning which had taken place as a result of incidents that had been raised previously. Staff also implemented required changes as a result of learning from incidents and safety alerts received. These were distributed to the matrons of each service and changes implemented.

The service always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. Staff made sure there was always continuity of care, including when people moved between different services.

Safety and continuity of care was a priority throughout people’s care journey. This happened through a collaborative, joined up approach to safety which involved staff and care partners. Staff discussed an example of where this had occurred the previous day as a result of a deterioration of a child. The transition back to acute care was seamless and ensured the safety of the child at all times, whilst also ensuring the family were involved along the way.

There was a strong awareness of the risks to people across their care journeys. The approach to identifying and managing these risks was proactive and effective. The service were leading on the transition pathway for children who were transferring from a children’s hospice to an adult hospice. At the time of our inspection, staff told us the age range for the service was 0 year to 25 years to cover the transition of the child requiring hospice support at an adult service with the planning for this at the older age range of what is considered to be a child. However, the service acknowledged admitting patients after the age of 18 was difficult at times due to the different needs of an 18 to 25 year old and therefore were considering the age range to 0 to 18 years and the planning for transitioning starting around 14 years (although this may be child dependent and taking into consideration any complexities). This had been given careful consideration following examples discussed during the inspection and previous reflections and feedback around how transitioning had occurred. To ensure all risks and needs were considered and managed, the service worked closely with transition leads from the acute services as well as partner services. There was a policy in place to support this pathway which identified the need for a multidisciplinary team approach which included key external organisations.

The service worked well with people and healthcare partners to fully understand what being safe meant to them and the best way to achieve that. Staff had a clear focus on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They always shared concerns quickly and appropriately.

There was a strong understanding of safeguarding and how to take appropriate action. All staff knew how to identify children and adults at risk of or suffering significant harm. Staff were aware of the relevant safeguarding policies, which were based on national guidance and legislation and followed them if they had concerns.

There was a commitment to taking immediate action to keep people safe from abuse and neglect, which included working with partners. There was a safeguarding lead for the service who was level 4 trained in safeguarding and had worked hard to establish good links with partners and worked with them to protect vulnerable children. Staff told us they rarely had the need to raise safeguarding alerts themselves, however many children they provided care for were known to the local authority and had safeguarding plans in place. This required close work with partners to ensure these children remained safe. Staff discussed examples where they had been involved in multidisciplinary safeguarding cases and the impact their role had in ensuring children and young people were kept safe.

Staff now received safeguarding training specific for their role on how to recognise and report abuse. Managers told us there had been changes to staff job descriptions recently which meant an increase in the number of staff requiring level 3 safeguarding training. Current training compliance with safeguarding level 3 training was 96%. Staff told us the level 3 training was comprehensive and was in line with the intercollegiate guidance.

The trustees were aware of safeguarding procedures and completed relevant training to their position. They attended monthly safeguarding meetings and received specific safeguarding updates from the chief executive.

Where applicable, staff had a clear understanding of the Mental Capacity Act. The majority of patients who were admitted to the hospice were of an age which was not relevant to these legislative requirements. However, as the service occasionally admitted older patients to the service including those transitioning to adult services, staff were required to have an understanding. Staff were knowledgeable about the Mental Capacity Act and supported patients to understand their rights.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There was a balanced and proportionate approach to risk that supported people and respected the choices they or their parents made about their care. Risks were assessed and people (where appropriate) and staff understood them. Staff completed comprehensive risk assessments for each child on admission using recognised tools, and reviewed them regularly. Staff included the parents of the child to complete risk assessments, especially for any updates on the child’s conditions in-between admissions to the hospice. These risk assessments included but were not limited to a child’s risk of skin damage, manual handling assessment, nutritional needs and bowel function. We reviewed the documents for the 2 children who were admitted at the time of our inspection and found all records were comprehensive.

Staff completed dependency scores for each child which were determined by numerous factors including, but not limited to whether they experienced seizures, required suction and required turning regularly.

Staff used a nationally recognised tool to identify deteriorating patients and escalated them appropriately. Staff provided examples where they had escalated children out of the hospice in line with their individual risk assessments and specified plans.

The service had access to psychologists and psychotherapists who supported patients and their families in relation to bereavement and other psychological impacts of having a life limiting or terminal illness. Any children or young people who displayed concerning mental ill health would be discussed with either the GP or consultant in charge of their care and referrals required would be completed. If staff deemed the situation to be urgent, emergency care would be accessed.

The service detected and controlled potential risks in the care environment. Staff made sure equipment, facilities and technology supported the delivery of safe care.

There were processes to ensure most equipment and the environment were well maintained and safely met the needs of the patients admitted to the area. However, the building was known to be ageing and with this came some concerns over the safety of the environment. At the time of our inspection, the service were already undertaking refreshment work on the location. Staff told us the facility had previously been considered to be more of a social care service rather than a clinical service. The location had carpets running throughout including in the patient rooms. Sinkswere not compliant with relevant building guidance and bedrooms had wooden furniture which was hard to clean. Current work being completed was focusing on rectifying these issues to make the environment more compliant with current standards.

In addition to the immediate refreshment work, which was underway, the service had additional plans in place for a more substantive refurbishment. There were no dates in place for when this work would start, however this would include installing piped oxygen into the hospice.

The service had suitable facilities to meet the needs of the children, families and those close to them. This included a family room, a cold room (a specially designed room which was temperature controlled to enable deceased children and young people to remain in them) and sensory room. There was also an accessible bath for the children to use which had hoist provision for those who required this. All bedrooms were equipped with suitable hoists.

The service also had an activities room and hydrotherapy pool which were not in use at the time of our inspection due to the refurbishments which were being completed.

There were 3 resuscitation trolley’s, 1 in the main corridor, 1 in the hydrotherapy pool area and 1 in the conference centre where the children came for ‘stay and play’ sessions. The resuscitation trolley in the main corridor was the only trolley equipped with a defibrillator. Staff told us they had completed risk assessments and practice runs taking the defibrillator from the main corridor to the conference centre with no concerns identified.

We reviewed a selection of clinical consumable items including cannulas, dressings, airways, suction tubing, syringes and blood sample bottles and found all items were in date. We also reviewed 4 items of equipment and found their electrical testing and services had been completed.

Staff disposed of clinical waste safely. We observed staff correctly segregating clinical and domestic waste. Waste bins were enclosed and foot operated. Sharps bins were correctly assembled and below the fill line. The management and disposal of sharps and waste was completed in accordance with the services policy.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care that met people’s individual needs.

There were appropriate staffing levels and skill mix to ensure children received consistently safe, good quality care that met their needs. The hospice planned their staffing based on the dependency scores of the children they had admitted or weredue to be admitted. The service held weekly booking meetings which would inform the staffing requirements. Most children were allocated a nurse and a healthcare assistant as a minimum; however, the service had their own bank of staff which could enhance staffing if the dependency indicated additional staff were required. Alternatively, mutual support from the other 2 hospice locations would also be used. All nurses who worked within the service were either registered children’s nurses or learning disability nurses.

In addition to the staffing for the inpatient children and young people, the workforce was further complimented by social workers, physiotherapists, domestic staff and volunteers.

Managers told us there were 2 vacancies at the time of our inspection, 1 for an administration role and the other for a full-time clinical nurse specialist. Sickness levels were low as were turnover levels. Staff told us they enjoyed working at the service and several had been employed for many years.

Medical care was provided by two palliative care consultants who divided their time between an acute hospital and the hospice. Although no formal ‘ward rounds’ were completed, regular reviews of the children who used the hospice were completed to ensure their care was holistic and met their needs. The service also received frequent visits from local GPs for additional medical cover.

The service had 3 advanced care practitioners (ACPs) to provide additional medical support. Staff told us these ACPs would ensure there was always a member of staff to prescribe additional medicines if required. They would also be instrumental in providing any immediate reviews of children who were acutely unwell escalated to them by the nurses caring for them.

Medical out of hours staffing was provided by the consultants or a GP with palliative care interest, however staff told us they did not require their support very often. Additionally, there was an on call nurse, manager and clinical lead who were able to provide staff with support in an event of any escalation requirement.

Staff recruitment practices mostly made sure all staff were suitably experienced, competent and able to carry out their role. Managers told us there had been work completed to update the system used for recording staff recruitment and employment files. We reviewed a sample of files and found most files met the regulatory requirements of schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We observed disclosure and baring services (DBS) checks for all staff files we reviewed and found only 1 staff file did not contain evidence of the required references; however, we were informed this was as a result of a staff member returning to the service and the requirement to merge their staff files. However, there were some absences in relation to staff members occupational health clearance, specifically in relation to vaccinations. Managers were working to ensure all staff had evidence of their vaccination status and had recently arranged a new service level agreement to provide staff with a more formaloccupational health service which they could access to receive confirmation about their vaccination history.

Staff received training appropriate and relevant to their role. The service had set up their own training facility which was called the Acorns Academy. This provided not only mandatory training for staff but also additional competency training. Staff demonstrated the online training packages which had been devised for specific skills that staff were required to undertake whilst working in the hospice. This included written lesson information and video demonstrations which could be accessed at any time by staff if a refreshment session was required. Competency documents were signed and stored on the system and required staff to complete updates every 3 years. The system automatically alerted staff 90 days in advance of their competency expiring. There were currently 8 skills which had competency packages in place, however the practice development team were already identifying further skills which were to be added to this electronic library.

Staff were required to complete and update mandatory training which was comprehensive and met the needs of the patients and staff. Staff we spoke with told us they had completed their training and managers told us there were processes for monitoring compliance with mandatory training. Data showed overall compliance was 98%. Most of the topics recorded 95% compliance or above, with 9 topics recording full 100% compliance. Conflict resolution was the only subject with partial compliance recorded at 91%. Additional supporting information identified this was in relation to 4 staff members who’s training had just expired.

Staff received the support they needed to deliver safe care. Staff underwent appraisals in their roles. Data showed current compliance with appraisals was 97% (excluding staff who were on long term sickness and maternity leave).

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff protected patients from the risk of infection by maintaining the environment and equipment to ensure they remained visibly clean and tidy. The service had a cleaning service who provided cover between 7am and 7pm. Staff cleaned equipment after patient contact to reduce risk of cross infection.

Staff followed infection control principles when it came to the use of personal protective equipment (PPE). The service had an adequate supply of PPE for staff, patients and visitors to use.

The service had an approach for assessing and managing the risk of infection. Staff requested any details around the patients infectious status when transferring into the service to enable them to take the appropriate steps if required. Staff told us theyhad provided care for patients with known infections or colonisation (the presence of microbes without causing an illness or infection), however due to their current environment, they had limitations in accepting patients who may require protective isolation. Managers told us the future refurbishment work would include making the service suitable for children who were immunocompromised.

The service did not have a lead for infection prevention and control at the time of our inspection. Advice required for any specific needs of the children would be obtained from either the local acute hospitals or the child’s own GP service, which included advice around antimicrobial prescribing for example. Senior staff told us they were currently looking to recruit a lead for infection prevention and control for the whole of the Acorns Hospice Trust.

The service completed audits to provide assurance that both children and young people were provided with safe care in line with IPC standards. Environmental audit results showed compliance ranged between 72% recorded in April 2025 and 82% recorded in June 2025. Areas which were identified as not meeting the standard was in relation to flooring and a medication area which was not conducive for staff to prepare medicines in. Both of these issues were part of the refreshment work which was being completed at the time of our inspection. Hand hygiene compliance was included within the larger IPC audits. Hand hygiene practices were identified as achieving the standard, however the audits in April and May 2025 identified incorrect posters being displayed in relation to handwashing procedures. This was rectified by June 2025.

The service had a hydrotherapy pool for children and young people to use. The pool had regular water testing completed, and this was monitored to ensure the pool was safe for all children to use. Where a child or young person had a known infection or was colonised with a microorganism, individual risk assessments were completed to ensure the safety of their use for them and to reduce the risk of potential transmission to others. At the time of our inspection, the pool was not in use due to essential works which were required.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

There were appropriate arrangements for the safe management, use and oversight of medications including the controlled drugs (CDs). As part of the refreshment work, which was ongoing at the time of our inspection, the service had just opened a new medicines room. Staff told us the previous room where medicines were stored andwhere staff were required to prepare medicines for the children, was not a conducive environment for this due to lighting and the temperature within the room.

There was a new CD cabinet which had been installed in the new medicines room. This contained 2 separate internal cabinets, 1 for the stock CDs and the other for patients own CDs. Each cabinet had it’s own CD book stored with it. We reviewed a selection of CDs and found these were correct. Audit results related to CDs showed these consistently achieved 100% compliance.

The service had the support of a pharmacist who worked each Friday in a non-clinical role. They had been instrumental in ensuring staff had a more appropriate room where medicines were stored and managed. They had also started to modify the governance around medicines management which included updating standard operating procedures and policies, as well as updating the audit programme. The service also had a controlled drugs accountable officer.

Patients medicines were appropriately prescribed, supplied and administered in line with relevant legislation, current national guidance and best available evidence. Staff had access to the relevant formularies for administration of medicines for children as well as access to specialist staff at the local acute hospitals if required. We reviewed medication administration records and found these were completed accurately.

At the time of our inspection, the service did not have their own antimicrobial prescribing policy, and the service were not affiliated to any service (acute or primary care) to follow their antimicrobial prescribing policy. However, staff told us they were advised to seek advice from the child’s GP as they were likely to be the service who would continue with any ongoing medication. If a child had a more challenging infectious presentation which required antimicrobial therapy, staff also had the opportunity to discuss with microbiologists and pharmacists from the local acute hospitals.

The service had recently had a new oxygen cylinder store installed due to the requirement for a significant number of cylinders being available for use at the service. We found most of the cylinders were stored correctly within this room, however as the room had only just been opened, there was no warning signs identifying the risk relating to the storage of the oxygen cylinders. Senior staff told us these were on order and would be displayed as soon as they arrived.

The service completed audits in relation to the medication administration records, this looked at ensuring patient details were included, weights were recorded, allergies were recorded and route of administration included (amongst other factors). Results showed compliance ranged between 92% and 96%. Areas identified for action to take place related to no form of medication, patient details missing and not all transcribed charts were signed by the prescriber.