Midland Metropolitan University Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This is the first assessment for this service. This key question has been rated good. This meant the service was well managed and well led. Leaders and the culture they created endeavoured to provide good care despite a highly pressured working environment. There was good governance, although some areas had not been picked up as reported above in our review of safe care.

We have not awarded this service a score for Well-led.

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

The service had a shared vision, strategy, and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The Emergency Department’s vision was: “To provide a safe, sustainable and effective emergency department delivering high quality, timely patient care.”

This was articulated through performance standards such as taking a handover of patients, ideally within 15 minutes and always within 45 minutes and providing all patients with a full assessment within an hour of arrival. There was a desire to meet the national A&E waiting time standard of 78% of patients being admitted, transferred or discharged within 4 hours and less than 10% of patients should be in the department for more than 12 hours. These performance indicators applied to both the adult’s and the children’s areas. The department audited and measured itself against this and provided honest figures that showed when these aspirations were not met.

There were expectations the department should provide a service to people of all ages and backgrounds and to tailor its services to the needs of the local population.

There was ambition to develop the clinical model further to take account of pressures in the wider health and social care system. These resulted in the high levels of inappropriate presentation experienced by the department, and its predecessors from people who could have been treated elsewhere. This had already resulted in the provision of an urgent treatment centre (UTC) on the site and the development of the same day emergency care (SDEC) facility. There was an outline plan to take account of national models intended to reduce demand in emergency departments as well as to ensure that UTC and SDEC would have sufficient capacity to ensure they could provide a comprehensive service to those patients who did not need the facilities of the emergency department.

The department was predominately staffed by people who had worked in the predecessor departments at the Sandwell and City hospitals. Senior staff told us that the two departments had been different. This was not only in the processes and mechanisms they followed, but they also had needed to be ‘culturally aligned’, something that managers felt was going well. During our inspection we noted staff rarely mentioned at which hospital they had previously worked and when it was talked about it was not in a negative manner.

Many staff told us they were proud to work in the department and proud of the successes of the department. Staff worked well as teams and supported one another which mitigated some of the effects of the stress they experienced.

Staff did not raise concerns about bullying or inappropriate behaviour to the inspection team.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience, and credibility to lead effectively. They did so with integrity, openness, and honesty.

Managers and leaders had the right skills to perform their roles effectively. When we spoke to staff they expressed confidence in their leader’s abilities. Leaders worked well together, and we observed working that was both professional and cordial. Leaders understood the challenges the department faced and were engaged in the actions underway to achieve improvement.

Staff told us senior staff were often present on the floor that leaders were approachable and open to hearing about issues.

The department’s shift leadership model was based around identified senior medical and nursing leadership for the whole department on each shift with further senior staff identified as leaders for various “zones” within the department. This was implemented as an emergency physician in charge (EPIC), a shift co-ordinator overall nurse in charge (SONIC) with zonal leadership by consultants, specialist registrars and nurses in charge (NICs).

We attended huddles, SONIC meetings and the bed and flow meetings and observed the decisions made being effectively implemented through the department. When the department reacted to events staff often did so quickly because the required actions were already embedded in process triggered by the developing situation. For example, when there was a build up of ambulances waiting to handover patients, this resulted in a surge of activity to make space in the department and release those vehicles. Similarly, when the ambulance service requested an immediate handover of a patient to release the vehicle to go to an urgent case, this was quickly arranged.

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.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Patients and carers were given the opportunity to make their views on the service known. The department positively encouraged people to give feedback on the service. They took people’s views seriously and a made changes when appropriate. The department took part in the national CQC Urgent and Emergency Care Survey, but this information was not available to the assessment as the latest fieldwork had taken place prior to the new department opening.

There was a trust wide freedom to speak up policy, and this was governed through a structure and leaders with identified roles. This mechanism was to be used when staff had spoken up locally but not felt listened to. Local leaders within the emergency department demonstrated they believed staff’s freedom to speak up was important to the safety of patients and the wellbeing of staff and it was positively encouraged.

Leaders valued the insights staff brought through their contributions to meetings and other forums. Fortnightly clinical governance meetings were open to all staff, of all grades and role who worked in the department. We saw through the notes of these meetings all contributions were treated with respect and people listened to.

Staff were also happy to openly discuss the challenges and difficulties they faced with the assessment team were not worried to do so.

The service valued diversity in its workforce. Staff worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

The trust’s recruitment policies showed that equality and diversity was valued in the recruitment process. Diversity and inclusion were also valued in in the workforce. Leaders supported work towards an inclusive and fair culture by improving equality and equity for staff. Managers completed workforce race equality standard data collection monthly. Staff came from a variety of ethnic backgrounds which were representative of the people the department served and there was an inclusive culture.

Leaders made reasonable adjustments to support staff with disabilities to carry out their roles well and during our assessment visit heard about examples of this.

The service had clear responsibilities, roles, systems of accountability and good governance. Staff used these to manage and deliver good quality, sustainable care, treatment, and support. They acted on the best information about risk, performance, and outcomes, and shared this securely with others when appropriate.

The department had a clear structure management and governance which addressed clinical governance, performance and general management oversight including staffing. There was a clear framework of what must be discussed through meetings that had clear agendas. For example, the clinical governance meeting, which was open to staff of all grades and in all roles, had a timed agenda and, for example, discussed incidents and complaints and staff welfare as well as having a clinical discussion. Decisions made were recorded and disseminated. The delivery of action plans was monitored and managed.

The departments senior leadership met regularly. When, following our assessment visit we saw notes of recent meetings, we recognised the issues discussed as being those that staff and managers had brought to our attention. We also saw the concerns under discussion correlated with the department’s risk register.

Meetings for band 7 nurses were held regularly, and notes were taken and distributed. We saw examples that showed staff discussed outputs and actions from the clinical governance meetings, training, incidents and complaints. Improvement was prompted through a “topic of the month”, “wins and wishes” and “issues and solutions”

There were morbidity and mortality meetings where clinical staff discussed cases. These discussed both good and suboptimal care and when appropriate generated learning and action plans. These meetings were multidisciplinary, and we saw good teamworking, for example with the medical examiners and the palliative care team being involved.

Staff had implemented recommendations from reviews of deaths, incidents and complaints. All incidents and complaints fed into the department’s clinical governance framework. 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 they were discussed in sufficient detail, taken seriously, and when needed resulted in action plans.

The department participated in local clinical audits. The audits were sufficient to provide assurance and to identify needs for improvement. Staff acted on the results when it was required. All audits were managed within a suitable governance framework.

There were audits that assessed the department’s compliance with the guidance used to deliver care. This was reported monthly to a trust clinical effectiveness group that signed off new guidelines and assessed and monitored compliance. We saw reports that showed this audit activity was subject to oversight and gaps were identified, responded to and any ensuing action plans were monitored.

There was a comprehensive departmental risk register which was integrated within the trust’s overall risk management systems. The trust’s senior management could readily describe the highest risks on the register and were proactive in bringing them to the assessment team’s attention at the start of our visit. Similarly, when staff told us of serious concerns or worries these issues were usually present on the risk register.

There was good emergency and major incident planning which involved rehearsals and exercises. On one of the days of our assessment visit there was an exercise to rehearse, with other agencies, the department’s response to cases of a viral haemorrhagic fever.

The day-to-day operation of the emergency department was governed through an overarching policy in which was embedded standard operating procedures. These covered, among others, ambulance assessment, triage, paediatrics, majors, resuscitation and ambulatory majors. There was an additional standard operating procedure that dealt with co-ordination between areas and additionally the rest of the hospital.

There was a clear mechanism for recognising pressure and workload in the department and what the response should be including escalation and response at trust level. This system used an escalation matrix describing the status of the department or area by colour; green, amber, red and black. There were then operating procedures and processes stating how the situation was to be addressed. This included giving senior staff the authority to take decisions to enable patient flow, by, for example, deciding the speciality that a patient would go to in the absence of input by that speciality within 60 minutes. During our inspection we saw this was effective and well implemented. For example, when there was a high number of 14 ambulances waiting to handover patients, this triggered a response to create space by moving patients on, and within 45 minutes all but two patients had been taken into the department.

The department collected real time data about performance. This information was used to analyse what was happening in the department at the time and a key part of this was the patient flow intelligence tool used to track patient flow, particularly in respect of admissions into the medical bed base. It informed the processes, both within the department and in the flow and bed meetings that recognised and responded to emerging demand and capacity challenges. We saw it in constant use by staff at all levels to understand what was happening at any given time. Staff in the ambulance assessment area has access to information from the ambulance service’s computer aided dispatch system and they used this to understand and predict demand on the department from ambulance admission. They could see when they needed to make capacity in the department to accommodate ambulance arrivals and see when there was less demand and take advantage of the situation.

While staff had no complaints about the IT systems they used, several expressed concerns there were not enough terminals, and they sometimes had to wait to use one. They also expressed frustration that the devices logged out quickly when a key was not pressed for a while and this meant they were having to spend valuable time logging back in.

The service understood their duty to collaborate and work in partnership, so services work well for people. Staff shared information and learning with partners and collaborate for improvement.

Within the hospital, the emergency department co-operated with other specialities, and we saw staff worked hard to implement the quality standards that defined the performance expectations between the specialists and the department.

The trust was a key part of the local health economy’s urgency and emergency care arrangements and as such was in constant communication with the commissioners and other providers. We saw this in action when we attended the bed and flow meetings that involved other specialities, other providers and the commissioners.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome, and quality of life for people. They actively contributed to safe, effective practice and research.

Staff were given the time and support to develop opportunities for improvements and innovation and this led to changes in care delivery. Staff had opportunities to participate in research. Innovations were taking place in the service.

There was a proactive approach to improvement which was embedded in the department’s management and clinical governance structures. We spoke to staff who told us they saw improvement as part of their role, and this was particularly so for more senior staff.

Staff used quality improvement methods and knew how to apply them. The department had well documented processes and procedures and these had been developed through analysis of data and the way the department operated. This was the basis for improvement as those processes were improved and the changes to outcomes measured.

Staff participated in national audits relevant to the service and learned from them. These included those from external bodies such as The Royal College of Emergency Medicine and the National Institute for Health and Care Excellence, and those programmed by the trust’s clinical audit department and local initiatives.

Where improvements were proposed there were governance structures to ensure they were given sufficient scrutiny and they were subject to “signing off”. Changes were introduced in a controlled manner and were subject to analysis of the benefits.