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Archived: Birmingham Women’s Hospital Requires improvement

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Inspection Summary


Overall summary & rating

Requires improvement

Updated 2 November 2016

Birmingham Women’s Hospital provides a range of health care services to women and families across the West Midlands and further afield which include gynaecology, maternity and neonatal care, as well as a comprehensive genetics service. On average, the trust looks after 50,000 patients a year and carries out over 3000 operations. The trust also supports home births to women in South Birmingham.

The trust employs around 1582 staff, 119 medical, 550 nursing and 913 are from other disciplines. The hospital has 210 beds, 117 provided from maternity inpatient services, 53 from neonatal intensive care, this includes a transitional care ward, intensive care unit, high dependency unit, special care baby unit and 42 from gynaecology services.

We carried out an announced inspection visit from 12 to 14 April 2016 and two unannounced visits on 15 and 27 April 2016. This inspection was part of our comprehensive inspection programme.

We held focus groups with a range of staff in the hospital, including consultants, midwives, nurses, junior doctors, student midwives and nurses, administrative and clerical staff, pharmacists, domestic staff and porters. We also spoke with staff individually.

We inspected and reported the Termination of Pregnancy services (ToPS) under Surgery and Gynaecology services because the volume of ToPS activity did not warrant an individual report. For the same reason, aspects of end of life care for women and babies was inspected and reported under Surgery and Gynaecology and neonatal services.

Overall, we rated this trust as requires improvement. We found that safety and caring was good and effective, responsive and well led required improvement.

The senior team was visible and accessible to staff and managers were seen as supportive and approachable. Managers were keen to engage and include staff in service development. There were some concerns raised in relation to the Termination of Pregnancy service, however the trust had commissioned an external review to look at issues raised.

There was a positive and enthusiastic culture throughout the hospital. Staff were committed and passionate about their work and proud of the services they offered to patients. Staff were keen to learn and continuously improve and patients were very positive about the care and treatment they received at the hospital.

Our key findings were as follows:

Safe

  • Generally, there were sufficient numbers of consultants and middle grade doctors to provide good quality care and treatment for patients in line with the Royal College of Obstetricians and Gynaecologists guidance. However, in Maternity Inpatients from January 2014 to June 2015 there was 90-120 hours coverage per week which was below the Royal College of Obstetricians and Gynaecologists (RCOG) recommendations of 168 hours for the number of births.

  • There were established systems for reporting incidents and ‘near misses’. Staff had received training and were confident in using of the incident reporting system.

  • The latest national reporting and learning system (NRLS) data showed the trust reported 1,468 incidents to NRLS from January 2015 to January 2016. 96% were no harm or low harm (70% no harm). 33% of incidents took 31 to 60 days to report, with 23% taking more than 90 days to report. The Obstetrics specialty had the most incidents reported (838), accounting for 57% of all incidents. Gynaecology accounted for 18% and Neonatology for 17% of all incidents.

  • There were no cases of hospital acquired infections for example; Methicillin-resistant Staphylococcus aureus MRSA), Meticillin-Sensitive Staphylococcus Aureus (MSSA)or Clostridium difficile (C.diff) reported from December 2014 to December 2015.

  • There was a visibly high standard of cleanliness throughout the hospital. Staff were aware of current infection prevention and control guidelines and observed good practice.

  • All relevant staff had received appropriate levels of training for safeguarding children and safeguarding of vulnerable adults, supported by robust policies and procedures. The trust set a target of 100% for safeguarding children training level 1, and they achieved this. For level two, they set a target of 85% and they achieved 97%. For level three, the target was 85% and they achieved 87%. For adult safeguarding, level one the trust achieved 100% against a target of 85% and for level two the trust achieved 97%.

  • There were challenges to fill sonography vacancies in the outpatient department which resulted in long waiting times, in some cases in excess of five hours. Across the four maternity community teams there was a vacancy rate of 5.93%, although the recruitment programme was underway, the trust found it challenging to recruit community midwives.

  • Neonatal staffing levels could not meet the national standards of nurse to patient ratio. However, neonatal staff were working extra hours to fill in gaps on the staffing rota which ensured care and treatment was delivered in a timely manner.

Effective

  • There were challenges around appropriate fasting times for women awaiting surgery, in some cases women had been starved pre-operatively in excess of 12 hours which could have impacted on their recovery. Time without fluids was at least five hours which is longer than the two hours which the Royal College of Anaesthetists recommends.

  • People were given a choice of suitable and nutritious food and drink, and we observed hot and cold drinks available throughout the day. Women who accessed the birth centre used ‘smoothie’ making equipment to help meet their nutrition and hydration needs whilst in labour.

  • Patient’s religious, cultural and dietary needs were considered and food was provided in accordance with their requirements.

  •  Women were supported to feed their babies using their preferred method. The trust had been awarded UNICEF Baby Friendly Initiative (BFI) stage three accreditation. BFI focuses on staff knowledge and skills to support families with their infant feeding choices.   
  • The trust acknowledged that poor breastfeeding support had resulted in an increase of neonatal readmissions due to related feeding issues. This had been raised as a CQC outlier. The service had developed an action plan to address these issues. The action plan was comprehensive and we saw target completion dates were on track to be achieved.

  • Nine extra support staff had recently been recruited and trained to offer breastfeeding support in an attempt to improve skin to skin contact for new-born babies and improve breastfeeding initiation rates.

  • The hospital’s 2016 Patient Led Assessment of the Care Environment audit identified a score of 96.76% for ward food.

Caring

  • People were respected and valued as individuals and empowered as partners in their care across all services.

  • Women and their families were treated with dignity and respect and we saw outstanding caring attitude and particularly within Inpatient Maternity services.

  • Feedback from people who use the service, and those who are close to them was continually positive about the way staff treated people.

  • People told us staff went the extra mile in supporting women and provided continued help and advice to women who wanted to breast-feed.

  • Staff took people’s personal, cultural, social and religious needs into account and actively engaged with people to provide cultural sensitive care and treatment at every given opportunity.

  • People’s emotional and social needs were highly valued by staff and embedded in their care and treatment.

Responsive

  • There had been a long standing issue with the time taken to assemble an on-call second theatre team to perform emergency caesareans. This had been unresolved and on the risk register for more than five years. During this time audits had been completed and the case made for a second resident team, however, the divisional leadership team had been unable to secure agreement from the trust to take this forward.

  • We noted the information on medical terminations of pregnancy did not include the risk of a late gestation foetus showing ‘signs of life’ and the potential requirement to register with the coroner.

  • Bookings for pregnancy and birth at the trust were limited to ensure demand did not exceed capacity.

  • Bed occupancy for 2014/2015 was between 64% and 72%, however for 2015/2016 the bed occupancy ranged between 72% and 82% and both years were higher than the national average.

  • Within neonatal services bed capacity leads worked six days a week to organise patient transfers and admissions. The unit did not close to patients in need of admission however, at times the unit would delay ex-utero (babies already born) transfers until cots were vacant and staffing levels were appropriate.

  • BWH provided a neonatal transport service for babies to and from the West Midlands area. This did not include a baby stabilisation service. There were procedures in place should a babies condition deteriorate in transit. A comprehensive neonatal team of 16 trained staff were responsible for the transport service.

Well led

  • The trust had not captured through audit the risk to breach of its condition of registration of ToP services under the Health and Social Care Act.

  • There were challenges around governance arrangements and risk   management with termination of pregnancy service. For example, the new contract for the termination of pregnancy service had commenced in January 2015. At the time of the inspection training for staff had not been formalised despite concerns expressed by staff about the need for clarity regarding actions to be taken.
  • The concerns we raised in relation to infection prevention and control, and the management of medicines and intravenous fluids within surgery services had not been identified in the audits undertaken within the service.

  • We observed a very good relationship between clinical staff and NICU managerial staff. The unit managers described a good relationship with the executive managers.

  • Generally there was a culture of openness, flexibility and willingness was demonstrated amongst all the teams and staff we met.

We saw several areas of outstanding practice including:

  • Video books were available for women who did not speak or read English which meant women had access to information about the service and their care and treatment.

  • The trust was awarded a s (SDIP) grant by local commissioners to pilot a three year project to set up a Homebirth Service.

  • Gynaecology services had been successful in becoming an accredited British Gynaecology Endoscopy (BSGE) centre for complex endometriosis.

  • A five year contract for providing complex abortion care had been secured. This contract covered Walsall, Wolverhampton, Sandwell and West Birmingham and South Birmingham.

  • The bereavement service had developed an integrated care pathway for bereaved parents which ensured consistency in formation provided and had been developed to reflect the needs of patients and their families.

  • The neonatal intensive care unit introduced the routine use of pulse oximetry for all babies within 24 hours of birth or prior to discharge. This has been identified as significant in the early detection of critical congenital heart defects prior to the deterioration of the baby.

  • The outpatient gynaecology department provided fast rehydration to patients seen in the hyperemesis clinic resulting in a reduction in re-admissions and overnight stays.

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

Importantly, the trust must:

  • Ensure Healthy Start vitamins are stored securely in all community maternity team offices.

  • Medicines are prescribed in line with the trust policy.

  • All community midwives must attend safeguarding supervision in line with Department of Health requirements (Working Together to Safeguard Children, 2015).

  • Ensure the safe storage of medicines including intravenous fluids.

  • Improve the application of infection prevention and control procedures in relation to the use of personal protective clothing and equipment and hand hygiene.

  • Properly maintain all equipment and medical devices.

  • Provide secure storage for patient records across all clinical areas.

  • Ensure the project to develop a second emergency theatre team is progressed in a timely manner.

  • The trust must ensure all HSA1 certificates for termination of pregnancy are fully completed by the registered medical practitioners signing them.

  • Identify, monitor and mitigate all risks relating to developing the complex abortion service pathway. In particular, in respect of processes required and the impact on staff and patients of distressing elements of late gestation termination.

  • Provide training to ward staff caring for complex abortion services patients in the appropriate procedures for responding to late gestation termination of pregnancy where the foetus may be indicating signs of life.

  • Ensure team work between the complex abortion care service, ward teams and bereavement team and wider medical teams are strengthened to mitigate risks involved in late gestation termination of pregnancy.

  • Take steps to ensure multi-disciplinary team work is improved where clinicians from other trusts are contributing the care of patients.

  • Clarify the method clinician’s should use to establish consent to termination of pregnancy from adult patients with learning disabilities.

  • Ensure the data collected for the Neonatal Audit Programme (NNAP) reflects the care given within the unit.

  • Ensure staff receive mental capacity training in line with trust guidance.

  • Implement a system to assess, monitor and improve the waiting times across clinics in the outpatients and diagnostic departments.

  • Mitigate the risks relating to the health, safety and welfare of service users by regularly reviewing the risk register and include a timescale in completing any risks identified.

  • The trust must reduce the waiting times in the diagnostics department by having sufficient numbers of qualified staff.

In addition the trust should:

  • Review community midwives’ caseloads to ensure equitable distribution of numbers and complexity pending review of staffing planned for June 2016.

  • Review how patients are informed about and supported to clearly understand the process and all potential clinical elements of late gestation termination of pregnancy.

  • Develop and put in place agreed after care pathways for ward staff to follow to best support patients. These should address the needs of patients where they may differ in respect of the decision to terminate their pregnancy.

  • Review the procedures for pre-operative fasting to ensure food and fluids are withdrawn for the minimum length of time to ensure the safety of patients and the maintenance of hydration.

  • Ensure where best interest decisions are made on behalf of a patient that reasons for the decision and other options considered, are clearly recorded.

  • Review the application of its policy for the use of interpreters to ensure all patients who require an interpreter are offered an independent interpreter.

  • Ensure there are processes in place to ensure learning is shared between different parts of the service and there is improved communication across services to enable the development of best practice.

  • Review the process for escalation of clinical concerns to ensure a timely response is achieved.

  • Introduce measures to reduce or remove risks on the risk register within a timescale that reflects the level of risk and impact on people using the service.

  • Take steps to improve the accessibility and reliability of the electronic care planning system in place in gynaecology.

  • Consider the perception that gynaecology is not dealt with fairly and issues prioritised in the same way as for other services and take steps to ensure equity.

  • MEWS charts are completed appropriately.

  • Patients undergoing induction of labour are supported to continue the induction process within a satisfactory timeframe.

  • On-site consultant hours reflect the recommendations by the RCOG in relation to the number of births.

  • Use the capacity data captured to influence staffing levels and business plans.

  • Consider it provides the persons with the information they would reasonably need by giving patients leaflets about their post treatment, rather than being directed to go onto the website.

  • Consider it has a consistent system across all departments to flag up any learning disability patients.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 2 November 2016

Effective

Requires improvement

Updated 2 November 2016

Caring

Good

Updated 2 November 2016

Responsive

Requires improvement

Updated 2 November 2016

Well-led

Requires improvement

Updated 2 November 2016

Checks on specific services

Maternity (community services)

Good

Updated 2 November 2016

Overall we rated this service as good. There was good incident reporting systems and learning from incidents embedded across all four community teams and the home birth team.

Staff planned and delivered care to patients in line with current evidence-based guidance, standards and best practice. Record keeping was consistent and equipment was available, clean and tested at regular intervals.

Medicines were prescribed, administered and stored in line with the trust policy. Each team had a safeguarding champion and arrangements were in place to safeguard adults and babies from abuse and harm.

The ratio of community midwives to women was 1:120, which is above the recommended average of 1:96.

Mandatory training was well attended and appraisal rates were 95%.

Patients and their relatives spoke highly of the care they received in the community maternity service.

The community team leaders were not represented at directorate meetings. The teams demonstrated varying levels of effective leadership. There were good examples of effective strategic leadership however there were areas where local leadership required improvement.

Risks were reviewed on a regular basis, however there was limited audit of service provision and patient feedback.

Patients and their relatives spoke highly of the care they received in the community maternity service.

Maternity (inpatient services)

Outstanding

Updated 2 November 2016

Overall we rated this service as ‘outstanding’. Staff provided an excellent service to women and their babies. Incident reporting and learning from incidents was timely.

All clinical areas were visibly clean and well maintained. There were cleaning schedules in place and levels of cleanliness were audited regularly. Medicines and medical gases were stored appropriately. Medical records were completed and stored securely and accessed without delay 24 hours a day.

There were effective processes for safeguarding mothers and babies, despite staff shortages in midwifery, recruitment plans were in place to increase staffing numbers. Incorrect prescribing of medicine for reducing the risk of venous thromboembolism was a challenge for the trust, however this had been identified and addressed.

Evidence based care and treatment was provided and audited appropriately. Pain relief options were available to women and patient outcomes were monitored effectively using a maternity dashboard system.

Targets for breastfeeding initiation rates were achieved and there was a detailed action plan to address the neonatal readmission outlier. Staff were supported with education and training to achieve competences in practice. We observed excellent multidisciplinary team work and staff had a good understanding of the Mental Capacity Act 2005.

Staff genuinely respected and valued people as individuals and empowered them as partners in their care. There was overwhelming positive feedback from women and their families.

Patients’ emotional, social, cultural and religious needs were highly valued by staff and were embedded in their care and treatment.

There were excellent arrangements to support individuals with complex needs, through access to clinical specialists and medical expertise. Bookings for pregnancy and birth at the trust were capped to ensure demand did not exceed capacity and there was a robust high activity escalation policy.

Complaints and concerns were included on a performance dashboard and regularly monitored to improve the care and treatment for women and their babies.

The maternity service had a clear vision for the future was embedded in the culture of the service and staff were clear of the governance and management structure within the service.

There was a clear management structure, which included strong clinical engagement. Local leadership within the directorate was visible, approachable and supportive. Staff were actively encouraged to follow specialist interests within the service and constantly strived to improve care and treatment.

Managers actively sought public opinion about service development and improvement, and innovation was supported and encouraged within the service.

During our inspection a serious incident occurred. Family members were supported by the HOM personally and a robust package of debriefing, discussion and counselling was put in place. We observed support provided to staff following the event. Senior staff exhibited behaviour above and beyond expectation to ensure staff were supported in every way possible.

Neonatal services

Good

Updated 2 November 2016

Overall we rated neonatal services as good. Staff reported incidents, and lessons learned were shared with staff.

Nursing and medical staffing did not meet the national standards for neonatal unit staffing. The establishment of nurses were not sufficient to provide 1:1 care for the number of intensive care babies. However, the service worked towards meeting this target through a robust recruitment programme and staff backfilled vacancies to ensure babies received timely care and treatment.

Staff were aware of their responsibilities in regard to safeguarding. The unit was clean and provided an appropriate environment for caring for all levels of intensive care babies.

Care was evidence based and in line with good practice. Multidisciplinary working was good throughout the unit and parent involvement was encouraged. The unit did not meet the Neonatal Audit Programme (NNAP) standards due to inconsistent data entry.

Training within the unit was incorporated into daily activity. Staff were caring and considerate to both the needs of the baby and the wider family. Some members of the management team within the neonatal unit were newly appointed or held interim posts.

The responsibility for management of risks were not always clear. Staff collected capacity data, but this was not acted upon.

The culture of the service was a supportive one with staff working flexibly to provide care.

Staff were proud to work for the service. This was reflected by the many compliments parents gave around the care their babies received.

Outpatients and diagnostic imaging

Requires improvement

Updated 2 November 2016

We rated outpatient department and diagnostic imaging as requires improvement. Staff had a good understanding of the incident reporting process. Learning was shared and staff gave examples of changes in practice in response to reported incidents.

Staff provided a caring and compassionate service to patients. All communal and clinical areas were visibly clean with cleaning schedules in place. Records were completed and stored securely. Medication was stored appropriately and resuscitation equipment was checked daily and ready for use.

However, there were poor pathways in the antenatal clinic resulting in excessive waits for patients up to five hours. The excessive waiting times in antenatal clinic was not on the risk register and there was no monitoring system in place to assess the waiting times within clinics. Clinics often ran over and staff worked above their contracted hours to manage clinics. In some cases women were given two appointments for the morning and afternoon which meant a double journey which could have been avoided if the pathway was more effective.

Nursing staffing levels were generally good, however, there were unfilled sonographer vacancies within the diagnostic imaging department which contributed to the long waiting times across outpatients.

Staff followed the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DOLS), when making decisions about patients with disabilities and mental health issues.

Staff had effective supervision, appraisals were up to date and staff were encouraged to continue to update their professional development. 84% of staff attended mandatory training against a target of 85%.

There was clear leadership in both the outpatients and diagnostic imaging services.

Staff felt supported by their local leaders who were visible on the departments and provided an open door policy.

There were examples of innovative practice in both the outpatients and diagnostic imaging services. Staff were proud of the hyperemesis unit, acute ‘one stop’ gynaecology clinic, home birth team pilot and the e-learning package.

Gynaecology

Requires improvement

Updated 2 November 2016

We found surgical services (gynaecology) and termination of pregnancy services overall required improvement. Staff were kind and professional and attentive to patients’ needs. Patients felt informed and involved in their care and decisions about their care.

However we had concerns about the standards of infection prevention and control and the servicing and maintenance of equipment. The checking and storage of medicines, intravenous fluids and consumables required improvement.

Care and treatment was mostly based on evidence based guidance but we found food and fluids were withheld for unnecessarily long periods prior to surgery.

Training and professional development of staff were generally good but there had been a lack of training and preparation of staff for some physical and emotional aspects of late terminations of complex pregnancy. The fact that some members of the multi-disciplinary team were not directly employed by the trust reduced flexibility and affected the timely access to some aspects of care.

Services were planned and delivered to meet the needs of the local population and there was evidence of the service working with local commissioners to improve access for patients. However, we noted variations in the flow of patients, which had a potential impact on the efficient use of resources and the ability to respond to the individual needs/preferences of patients.

Local leadership within gynaecology was good, however, the priority given to gynaecology within the wider trust was perceived to be low. As a result there were challenges in moving forward with developments and addressing risks.

The governance framework had been strengthened and progress was being made in addressing the long standing issues. However, the trust had not captured through audit the risk to breach of its condition of registration of the termination of pregnancy services under the Health and Social Care Act or the issues we found in relation to infection prevention and medicines management.