Midland Metropolitan University Hospital

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• 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

This is the first assessment for this service. This key question has been rated requires improvement. This meant not all people were safe and protected from avoidable harm. This rating reflected a lack of compliance in updated safeguarding training for medical staff. Not all treatment was commenced in a timely manner due to pressures on the department from over-capacity. We were concerned about the visibility of patients who might deteriorate in the waiting area. There were failures to manage medicine stock safely and to give patients medicines on time.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

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.

There was a culture of safety within the emergency department with staff acting with openness and integrity. Staff had received training in incident reporting, were clear how to do so, and were able to describe incidents they would and had reported. The service managed patient safety incidents well and used the NHS’s Patient Safety Incident Response Framework (PSIRF) to respond to incidents. Managers knew how to investigate incidents within the PSIRF system, and we saw example incident reports that demonstrated this was done effectively. Staff received feedback on incidents they had reported.

Learning from incidents was disseminated within the department and if necessary, more widely. This was done following the completion of the investigation process through, for example, bulletins, meetings, changes to processes and training and this was managed through action plans. Following an incident there were immediate discussions actions managed ‘on the floor’ through planned and ad-hoc safety huddles led by senior staff from the relevant zone. When we spoke to staff, they could talk about incidents that had resulted in learning and changes to procedures.

Individual incidents and trends were discussed in governance meetings through standing agenda items. When we looked at the notes of these meetings, we could see that they were discussed in sufficient detail, taken seriously, and when needed resulted in action plans.

Staff and managers had been trained and knew about the duty of candour and could describe their individual role. Duty of candour is a regulation that requires providers to recognise when things have gone wrong as notifiable patient safety incidents. Patients, and if necessary, other persons must be told what happened, receive an apology and be kept informed of any safety investigation. We saw evidence of it being appropriately applied through recent reports and correspondence with patients and their families.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people moved between different services. However, because of capacity issues beyond the department and the hospital these arrangements were not always effective.

Patients presented to the department either as “walk-ins”, by ambulance, or having been referred by another service. The department relied on patient histories from themselves or ambulance crew and while this might sometimes be minimal, that which was provided was recorded and if possible, tied up with existing records for that patient. Sometimes patients had been given expectations by other providers that they would be seen quickly and this caused frustration.

There were clearly defined patient pathways through the department which were described in standard operating procedures (SOPs). Examples were ambulance assessment, resuscitation, majors, triage, ambulatory majors and minors, and paediatrics, both walk-in and ambulance. There were also pathways for specific presentations such as for patients with Sickle Cell Disease who were seen by a specialised team during core hours and admitted to the medical bed base outside of that. Pre alerted patients needing percutaneous coronary intervention had a pathway straight into the cardiac catheterisation operating theatre.

These pathways and processes were under constant review as to their effectiveness and we noted recent change made prior to our assessment visit as part of the review of the clinical model. Documentation for all this was clear, consistent and to a good standard.

When we observed the activity within the department, we saw the SOPs were consistently applied. When a change to the way the department was operating was required, by for example capacity issues triggering an action, this was done. The result was that the department operated smoothly and effectively despite pressure and reacted well to external and internal challenges.

Pathways out of the department were varied. Amongst other options patients could be sent home, admitted to the hospital or referred to another provider. There were pathways to admit patients into the bed base, and this involved decision making as to the appropriate speciality with input from that speciality. There were defined ‘quality standards’ for the time in which the specialities should respond as well as the option for the most senior doctors to decide in the absence of input. There were referral pathways to other providers for patients who needed specialist care elsewhere.

While the procedures were well defined, the process itself was hampered by lack of capacity in the hospital, adult social care capacity in the community and with other providers. The latter particularly for patients needing mental health referrals, and even more so for patients who were not resident in the area.

Staff told us changes to the way the police managed patients who had been arrested in a public place had placed greater pressure on the department. We saw how the department was working proactively with the police, and particularly so with the Sandwell Area Command to address concerns. However, because of the location of the hospital, many people brought by the police were from the city centre with its national transport links and so were often not residents of Birmingham and Black Country. Anecdotally staff told us this represented half of the patients brought by the police, and during our visit we saw staff working hard to repatriate a patient to their home hundreds of miles away. The figures for the previous 4 months showed that the percentage of out of area patients was between 13% and 40% with an average of 25% meaning a quarter of all those patients were from brought by police lived outside of Birmingham and the Black Country.

There were shortfalls in some of the training of staff. However, the service collaborated with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The service shared concerns quickly and appropriately.

The trust had a target of 95% for the completion of safeguarding training for the various levels that different groups of staff were expected achieve. We requested compliance information from the trust and while the figures we saw were difficult to interpret it was clear that there were shortfalls in the training of medical staff with no training appearing to meet the requirement.

For the safeguarding of adults training only 76% of medical staff were up to date with level 1 training, 72% with level 2 training and 27% with level 3 training. For the safeguarding of children medical staff requiring level 1 training had a compliance level of 76%, for level 2, 72%. However additional training requirements had recently been added and so some of this shortfall represented that this training was ongoing[KW1] .

For nursing staff, compliance with safeguarding met the target for all levels of training for both adults and children.

Safeguarding information was recorded on the Electronic Patient Record (EPR) and if appropriate raised a warning flag for subsequent presentations.

Many people attending the department had potential vulnerabilities and consideration of this was included in the assessment of all patients. During our visit we saw good examples of safeguarding taking place and this included an example of professional curiosity and challenge to another agency’s view, which resulted in the protection of an individual who might otherwise have been missed.

Staff were confident when talking about safeguarding and able to describe how to recognise abuse or vulnerability and what to do. Most staff could describe a safeguarding issue that they had reported or were aware of.

There were link nurses staff could talk to for guidance and advice. Staff in the children’s area told us that when needed, they got advice and support from colleagues on the paediatric wards.

Because of workload and crowding, people at risk were not always identified and treatment was not always started in a timely manner. We were concerned about patients not being visible in the crowded waiting area if they deteriorated. However, 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 standardised approach to assessing and recording each patient’s condition using nationally recognised tools. Patients received a comprehensive assessment on arrival, and this was updated dependent on their condition, needs and risk score. Examples included assessments of risk from pressure ulcers, deep vein thrombosis, nutrition and hydration, and falls. Because of much longer stays in the department there had been modifications to these assessments because of the risks of being on trolleys and seats rather than in beds. When a concern was triggered due to the time spent or the patient’s condition, action was taken. This issue of longer stays was noted on the departmental risk register with various actions to mitigate the potential harm.

Alongside the rest of the hospital the department used the National Early Warning Score (NEWS2) system to record each patient’s condition and identify whether they might be deteriorating. This recorded clinical and physiological observations such as breathing, heart rate, temperature and blood pressure and produced a ‘score’. When certain thresholds were reached action was required. The NEWS2 system included an assessment as to whether the patient was at risk of sepsis and if this was so then a package of treatment known as a ‘sepsis bundle’ was initiated.

A similar approach was taken in the children’s area of the department with the use of appropriate tools for the age of the child. Prior to our inspection, we were made aware that the department’s computerised Paediatric Early Warning Scoring (PEWS) system incorporated an error. This meant that under some circumstances it was calculated as too low and poorly children would not be identified. This had been identified through the investigation of incidents and manual processes were used as mitigation. All staff to whom we spoke were aware of this and the manual process was being used.

Regular safety huddles took place within the department’s different zones around a ‘SWARM Board’ and at these both overall and individual patient’s risks were discussed. There were also regular oversight meetings of the department’s senior clinical staff including the senior nurse in charge (SONIC) and the emergency practitioner in charge (EPIC). These took a higher-level view but also discussed individual patients when necessary.

Despite this, there were instances when it was not recognised that patients had deteriorated and when treatment plans were not carried out in a timely manner. This was identified within the department through audits and through the investigation of incidents. Staff were candid about these issues, and we saw actions took place to prevent recurrence. For example, we saw recent communications saying there had been an increase in incidents caused by delay in giving treatment, including the starting of the sepsis bundle, and staff were reminded of the “expectations to monitor, escalate, action without delay, ask senior staff for support” and “think about location, do they need to move?”

Asked about their highest worry, many staff talked about the adult waiting room which was frequently crowded and where patients might become unwell without being noticed. There were expectations that staff would monitor the area but there was no formal process for doing so, a shortcoming that had been identified and was being worked on. One initiative was to ‘pull’ patients complaining of chest pain from the waiting room for an early electrocardiogram (ECG) to identify any that were seriously unwell.

We were told of incidents that had occurred of patients becoming acutely unwell while waiting both in the waiting room and while waiting for definitive treatment in the rest of the hospital.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. However, the waiting area was frequently crowded and not always safe or comfortable for patients.

The ED was purpose built and completed as part of the new Midland Metropolitan University Hospital in the October of 2024, 1 year before our assessment visit. The department was located at ground level with access ramps from the adjacent main road for ambulances and a dedicated parking area for them next to the department’s ambulance entrance.

Patients arriving on foot could be dropped off outside the walk-in entrance or come up from the large underground car park, which we noted, had spaces available at all times of the day. There were separate walk in entrances for adults and children. The main entrance to the hospital was located some distance away from the ED and provided easy and well signed access to the reception area located on the 5th floor by lift. However, a common complaint from staff was that members of the public, and particularly taxis, dropped patients and visitors off outside of the ED meaning they walked through the patient waiting areas to lifts that were not designed to take the amount of people. This was despite strong signposting to the main entrance for motorists.

Walking-in adults arrived in a spacious waiting area and were clearly directed to a reception and triage area. This waiting area had suitable seating and a small coffee bar and vending machines. Cups of water were always available. However, during our assessment visit we noted the area was frequently crowded, and sometimes patients and relatives could not find a suitable seat. This was exacerbated by some patients taking up more than one seat by lying down across chairs. An area of the waiting room was often occupied by patients accompanied or escorted by police or prison officers. Many patients chose to stand rather than take a seat in this area.

Patients arriving by ambulance either went straight to the 10 bedded resuscitation area if pre-alerted or to the ambulance assessment area. Because of crowding in the department some patients were held on ambulances for some time before they could be accommodated in the department. However, like the crowding in the waiting room, this was not a fundamental failing in the size or design of the department but rather the inability for patients to be transferred to other areas of the hospital, other providers or discharged quickly.

Patients were streamed to the 8 minors cubicles or the 26 majors cubicles. There was a ‘fit to sit area for patients assessed as safe to sit with other patients and not need their own cubicle or bay. All areas were suitably equipped and some of the majors cubicles were equipped with fixed patient monitors. For other areas portable monitoring was used and staff told us there was sufficient equipment available.

Two of the majors cubicles were designated as suitable for patients with mental health issues, and these had a reduced level of equipment to limit the risk of people harming themselves.

One resuscitation bay was equipped for children, and another was dual equipped for both adults and children. There was a specifically designed area where relatives could view people who had died in the department.

As recommended by NHS England, there was a separate children’s area that was distinct from the main department and provided what was effectively a separate children’s emergency department. Walking-in children had a dedicated entrance through which people had to be admitted by staff. This led into a children’s waiting and reception area which was suitably equipped and decorated. However, this was often crowded and there were signs indicating that when the department was busy, which was often, only one carer could accompany a child. Staff told us that this was often a source of friction between them and parents.

The imaging department was located on the same floor as the emergency department and afforded easy access. As well as projection radiography sets there were also 2 computerised tomography (CT) scanners and a magnetic resonance imaging (MRI) machine. The MRI was available from 8am to 8pm and the CT scanning was available 24 hours a day with one machine dedicated to the emergency department. Staff told us that scans were usually available with 30 minutes and for suspected stroke or head injury patients would be scanned immediately.

The emergency department was also located close to the ambulatory medical assessment unit, the surgical assessment unit, the acute medical assessment unit, and the cardiology department. These areas received most of the admitted patients from the ED, but, except for the ambulatory medical assessment unit, were not included in this assessment. There were specific pathways to these areas, for example, patients with some types of heart attack had direct access to the cardiology department and its catheter laboratory.

Staff and managers told us that facilities for patients with mental health issues were unsuitable for the time many of those patients had to wait in the department for a suitable placement in another hospital. There were two cubicles used to accommodate these patients which kept them safe, but as this could be for several days it was not a good place for them to stay. The department had been designed with a special facility for area for accommodating patients who had been detained by the police using section 136 of the 1983 Mental Health Act. However, this was too small for the number of patients, and it was being used as office space by a mental health team from another provider.

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

At the time of our assessment visit the emergency department had, the previous day, introduced a new clinical staffing model. The department, which had brought together the staff from the now closed emergency departments at the Sandwell and City hospitals had been operating with all those staff since opening a year previously. Achieving economies of scale was part of the vision and plan for the department and this was intended to take place once staff were embedded into the new department and there was an understanding of how the new department worked in practice.

Staffing levels were designed to achieve the department’s vision and performance standards and to largely meet national recommendations but within the trust’s financial constraints. These models had been piloted, adjusted as necessary, and signed off as suitable. For example, in the majors area the original model, based on Royal College of Emergency Medicine (RCEM) and Royal College of Nursing (RCN) standards of 1 registered nurse to each 3 cubicles, (1:3), was now 1 to each four cubicles, (1:4), with a healthcare assistant (HCA) to support. Similarly staffing for the cubicles with physiological monitoring, where patients could be expected to be sicker, was reduced from 1:2 to 1:3. We saw comprehensive documentation that demonstrated the model had been developed on the back of clear principles which demonstrated benefits as well as recognised associated risks.

Some staff expressed concern as they started to work in the new arrangements, but we saw no evidence of failures of care attributable to the new arrangements during our assessment visit.

Staffing models also took account of the time of the day, and the day of the week that patients presented to the department, as well as, as far as practicable, the acuity of patients at different times. These models had been developed based on departmental data, with consideration of national guidance and risks were explored. Governance arrangements meant they had been signed off at trust board level.

The department was a trauma unit, and staff were suitably trained. All patient facing staff had basic life support (BLS) training, all band 5 nurses were immediate life support (ILS) trained and all nursing staff higher than band 5 were trained in advanced life support (ALS). On all shifts at least 3 nurses had the trauma nursing core course (TNCC) qualification.

In line with recommendations from NHS England, the children’s staffing was separate, and children were looked after by a separate clinical team within their own paediatric area.

Managers told us the establishment in the children’s area was good, but they did have trouble filling shifts because of sickness and recruitment. There were paediatric emergency medicine consultants with dedicated time allocated to the role. There were 4 nurses on duty at any time plus 2 extra on twilight shifts which were the busiest times. All nurses were registered children’s nurses or had paediatric experience. All nursing staff in the children’s department had the paediatric immediate life support (PILS) qualification and at least one nurse per shift had an enhanced or advanced paediatric life support (EPLS or APLS) qualification. Although we were told that occasionally it was not possible to have an EPLS or APLS qualified nurse on duty, the skill mix always met the recommendations of the Royal College of Paediatrics and Child Health (RCPCH) for safe staffing of emergency departments that treated children. Some staff in the children’s department expressed concern that there was no longer a band 7 nurse on nights to provide the experience and support that they would like.

Where there were staffing pressures and shift vacancies caused by sickness and absence these were largely covered by bank staff. Agency staff made up only 15% of the temporary cover and these were largely used for enhanced and one to one care.

There was little use of locum doctors with temporary shifts being covered from the trust’s own staffing pool.

Overall sickness was 5.8% against an England average of 4.9% When we discussed this senior staff told us there was a recognised concern with illness caused by the high stress of working in the high intensity environment of emergency departments.

Staff received development opportunities and support was provided by the band 7 practice development nurses who were also responsible for the oversight of mandatory training. There was a development programme for band 5 nurses and one in development for the band 6 nurses. When incidents occurred, we saw these were often taken as learning opportunities with discussion and teaching at handovers and safety huddles.

Security staff were employed directly by the trust and had received suitable training to carry out their role. Senior security staff also carried out training for clinical staff to keep themselves safe and to deescalate situations.

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.

There was effective governance and oversight to assessing and managing the risk of infection which was in line with current national guidance. Managers carried out infection prevention and control audits including for hand hygiene. Where shortfalls were noted action plans were commenced and the reports contained photographs which made it easier for staff to resolve any issue.

Despite crowding in some areas of the department, we found clinical areas to be visibly clean, tidy and without clutter. The main patient waiting room felt cluttered because of the way it was being used by some patients, but cleaning staff were noted to be dealing with spills and littering. There were plenty of patient toilets in this area and they were noted to be visibly clean. Non-patient areas tended to be more cluttered, and we noticed some equipment, particularly computers were dusty.

Medical devices and other equipment and items were cleaned between patients and were labelled as such. Staff adhered to uniform policy, and we did not need to raise any concerns during our assessment visit.

There were suitable facilities for hand hygiene throughout the department with washbasins and hand gel dispensers readily available. Staff made use of these, and we had no concerns about hand hygiene during our visit.

Staff had access to personal protective equipment including specialist items for use in major incidents. Staff adhered to the uniform policy and were bare below the elbow, although there was provision made for those staff that needed to go outdoors to see patients on ambulances to wear long sleeved jackets. For this activity the risk was assessed and mitigated.

Staff received suitable training in infection prevention and control through their induction and as part of their mandatory refresher training. Of the nursing staff, 92% were up to date with this training but only 61% of medical staff.

The service did not always make sure medicines and treatments were safe and met people’s needs, capacities, and preferences. There was no clinical pharmacy service based within the emergency department. Although there were processes to ensure people received their medicines as prescribed, sometimes medicines were not always available or administered on time.

There was no clinical pharmacy service based within the emergency department. The Royal College of Emergency Medicine advises that emergency departments have a dedicated clinical pharmacist. Also, a pharmacy technician working as part of the multidisciplinary team to help provide clinical and operational support for the safe and efficient delivery of care to patients. A trial with a pharmacy technician (April 2025) demonstrated the value and benefit of having a pharmacy presence within ED. They made 93 clinical interventions and ensured there were supplies of medicines to prevent any missed doses. A pharmacy technician visited ED for an hour in the morning (Monday to Friday) to help support and prioritise patients prescribed time critical medicines. However, this role was not funded.

Nurses had access to medicines from wards, an out of hours cupboard, and could contact pharmacy for supplies. A critical medicines list was available and there was access within ED to time critical medicines such as for Parkinson’s Disease. However, we noted one patient had not received a time critical medicine because it was not available in ED. Nursing staff were concerned that patients in ED were not always given their regular medicines.

Patients’ medicine history was taken and recorded using access to patients’ primary care records where appropriate.

Staff completed medicine administration records accurately. Patients’ allergy status was recorded which meant medicines could be prescribed safely. The weight of patients was recorded when prescribing weight-based medicines. Sepsis was treated following antimicrobial guidelines which included documenting the reason and the administration of antibiotic treatment was recorded.

Guidance was available to support the monitoring of drug treatments, particularly for high-risk medicines requiring therapeutic drug monitoring.

There was a system for the provision of certain medicines such as pain relief or antibiotics for patients discharged from ED. Staff were able to talk through the process or managing and reporting any errors or incidents involving medicines. Staff told us they had online access to relevant medicine policies, procedures and guidelines. Patient Group Directions were available to enable nurses to administer medicines for certain conditions.

Medicines were locked and secure and were stored safely in line with recommended practice. However, inaccurate stock levels meant that medicines were sometimes not available.

Medicines, including controlled drugs (CDs) were stored securely and appropriately with access only to authorised staff in accordance with policy. However, nursing staff did not always record the total amount of medicines removed from the automated digital storage unit which meant medicine stock levels were often inaccurate. Medicines were therefore not automatically re-supplied when levels were low, and patients were at risk of not having medicines available when needed.

Staff told us that pharmacy conducted audits on the safe and secure handling of medicines including CDs. We saw evidence of storage audits with action plans where issues were identified. Medicines for refrigeration were stored securely with records available of temperatures to ensure the medicines were stored safely. Staff knew what action to take if there were any issues to ensure the safe storage of medicines.

Medicines required in a medical emergency were checked regularly and were readily available when needed following Resuscitation Council (UK) guidance. Prescription stationary was stored securely with records available in line with NHS Counter Fraud Authority guidance.