All inspections: Birmingham Heartlands Hospital

The trust had undergone significant changes in senior and executive management due to the trust not meeting nationally identified targets. We used the intelligence we held about the hospital to identify that we needed to undertake a responsive inspection of the Emergency department (ED), Medicine, Surgery, Critical care and Outpatients and Diagnostic Imaging. In relation to Critical Care we inspected this service as it had been rated good previously and wanted to see if it had improved further.

The inspection took place with an unannounced inspection on 06 September 2016 and on that day we gave the trust short notice of our return on 18 to 21 October 2016.

We did not inspect Maternity and Gynaecology, the trust had commissioned an independent review which was taking place at the same time. We thought it would be excessive to have two inspection teams putting undue pressure on the staff on the units. We also did not inspect Children and Young People and End of Life services.

We rated Birmingham Heartlands Hospital by core services only, and have not aggregated the location overall, as we have did not undertake comparison services in full. We have described the previous inspection findings compared to this in the provider report. .

Within the Emergency Department (ED), capacity was the issue, having not met the national targets for some time. We saw that because of the number of patients coming into the department they needed to wait in corridors on trolleys.
Ambulance handovers were delayed, which increased the turnaround time of the vehicles. Also people then waited longer to receive treatment.
The flow did not appear to be working effectively all the time, we saw majors patients who required triage within 15 minutes which was not taking place.
Pain relief was not always given to patients in a timely fashion. We received feedback from patients regarding this.
Within medicine, staffing was an issue, which meant the hospital had to use bank and agency staff regularly.We also saw that the hyper acute stroke unit did not meet the British Association of Stroke Physicians guidelines for staff to patient ratios. Within critical care access to allied healthcare professionals did not always meet national guidance.
Delayed discharges were an issue both in medicine and surgery, with regard to the arrangements managed by hospital staff and the impact of insufficient porters and patient transport issues (please note the patient transport outside of the hospital was operated by another provider).
Medical outliers were having a negative effect on patients. The wait was longer for specialist input from professional staff.
The hospital had four never events between August 2015 to July 2016.Three of these related to the surgery directorate.
Medicines management needed to improve in terms of the storage and checking arrangements both in surgery and the outpatients department.
Some patients assessed as requiring a pressure-relieving mattress waited too long which put them at risk of skin damage.
Within critical care we saw that the environment prevented the staff from delivering care to an optimum level.We noted that the rooms designated for infectious patients did not have modern facilities such as negative air pressure to reduce the risk of cross infection.
Outpatients did not always ensure the security of patient records, risking other people seeing them.
Clinics often did not run to time causing delays for patients who had arrived on time. Staff were concerned that the late tickets were at risk of being rushed.

However;

Access to staff training, MDT working and the arrangements in place to support stroke patients in ED was good.
Staff were observed throughout the hospital as caring and patient focussed. We saw compassionate care amongst the critical care staff.
Leadership and culture within critical care promoted high quality care.
Incident reporting was particularly well embedded within outpatients and diagnostic imaging.
Five steps to safer surgery checklists were used to maintain patient safety.
In outpatients we saw that patients and families were partners in their care, given sufficient information to make informed choices.
Clinics were available outside of core hours to help patients.

We saw several areas of outstanding practice including:

ED

The trust employed a nurse educator for the ED specifically to ensure nursing staff are competent practitioners. Newly qualified staff had a local induction and a period of preceptorship. Newly qualified staff that we spoke to told us that they received very good support.
The nurse educator told us in detail about the training plans for the ED nurses.

OPD DI

We saw an example of outstanding practice in the imaging department. There was an excellent induction document introduced by senior imaging managers. This gave radiographers opportunities to reflect on their practice and innovative ways of thinking about how they work.After staff had completed the induction, a discussion took place between the radiographer and the on-site lead. This also ensured staff had the necessary knowledge to practice safely.

Importantly, the trust must:

The trust must ensure that the premises are suitable for the service provided, including the layout, and be big enough to accommodate the potential number of people using the service at any one time.
The trust must consistently ensure medicines are stored appropriately and are suitable for use.
The trust must review and improve security and access arrangements at the unit.
The trust must review its clinical waste storage at the unit.

In addition the trust should:

The trust should consider that patients have a pain assessment and are provided with pain relief which is timely.
The trust should mitigate and action risks on the risk register by regularly reviewing the risks in a timely manner.
The trust should consider a review of the appraisal system to ensure that they are all meaningful and that those areas with low completion rates, staff review and target.
The trust should ensure local rules for lasers are signed and in date.
The trust should ensure service records for lasers in ophthalmology are up to date and accessible for relevant staff.
The trust should ensure there is a robust system in place to monitor infection control and hand hygiene compliance in the main outpatient clinics.

Please note all the ‘Musts’ and ‘Shoulds’ can be found at the end of the report

Professor Sir Mike Richards

Chief Inspector of Hospitals

Heart of England Foundation Trust is a large NHS provider of acute hospital and community services in Birmingham and Solihull. The hospitals are in the East and North of Birmingham and one smaller site in Solihull West Midlands. There is also the Birmingham Chest Clinic which is in the centre of Birmingham The trust has some community services in Solihull. We did not inspect the community services or the Chest Clinic. The three acute sites are Birmingham Heartlands Hospital, Good Hope Hospital and Solihull Hospital. Along with the community service the trust serves approximately 1.2m people. The Birmingham Heartlands site is where the trust headquarters are located.

We carried out this unannounced responsive inspection because the trust was in breach with regulators Monitor, and we had received intelligence which warranted our response and so we arranged the inspection. The inspection took place between 08 and 11 December 2014. We had inspected the service in November 2013 and the trust was still working through compliance action plans.

This inspection was an unannounced responsive inspection and as such we will not be rating the service. The purpose of the report is to share with the trust and the public the evidence we gathered during that inspection. It is also important to note that at the time the trust was in transition with many changes within the trust executive team, some of whom were in interim posts. This had been precipitated by the previous Chief Executive resigning in November 2014.

Our key findings were as follows:

Widespread learning from incidents needed to be improved.
Appraisals for staff were not widely undertaken achieving 28% compliance at the time of our inspection.
Staffing sickness and attrition rates were impacting negatively on existing staff.
The congestion within the hospital was having negative impacts across all the core areas we inspected. For instance the number of patients having to wait in recovery more than 30 minutes was high.
Discharge arrangements required improvement; we saw that only 35% of patients were discharged on or before their planned date of discharge.
The care of the deteriorating patient was generally managed well.
Arrangements for patients with reduced cognitive function were not always effective. This meant that some patients did not receive the level of care and support they required.
The leadership was in a transition phase with many in interim posts.
The culture within the trust was one of uncertainty due to the number of changes which had occurred.
Staff could not communicate the trust vision and strategy.
Governance arrangements needed to be strengthened to ensure more effective delivery.
IT reporting needed to be improved to ensure reporting was accurate.

We saw several areas of outstanding practice including:

On the Acute Medical Unit (AMU) at Birmingham Heartlands Hospital (BHH) local complaints resolution was very responsive to patient’s needs. The complainant was invited to a meeting and given a recording of the discussion. This appeared to resolve complaints quickly.
AMU, Ambulatory Care, wards 10, 11 and 24 provided excellent local leadership, services were well organised, responsive to patients individual needs and efficient which resulted in excellent patient outcomes.
The Practice Placement team provided excellent links between the trust and the University in supporting more than 600 student nurses across all three hospital sites.

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

BHH Emergency department appeared at crisis with overcrowding and lack of flow, leading to a high stress, high risk environment for both patients and staff.
Arrangements for patients who required mittens were not undertaken to maintain patient’s safeguards.

Importantly, the trust must:

The trust must take effective action to achieve consistent staff compliance of infection control procedures within the emergency department.
The trust must address the ambivalence held by staff about reporting incidents as they may be underreporting and trust could miss important trends.
The trust must ensure that staff are clear about clinical responsibility for patient’s awaiting handover by Ambulance services in the emergency department at Heartlands.
The trust must take effective action to address the crowding in the majors area of the ED department and ensure that staff on duty can see and treat patients in a timely way.
The trust must ensure all patients requiring items of restraint such as hand control padded mittens are supported with a mental capacity assessment, a DoLS and are regularly reviewed by the MDT which is recorded in the patient’s notes and mittens are replaced when soiled. A consistent practice must be adopted across the trust.
The trust must provide sufficient staff to operate the second obstetrics theatre at night, and prevent delays occurring.
The hospital must improve the information available to outpatients departments to ensure that these are monitored and action taken to improve services through audit, trending and learning.
The trust must take effective action to address the overcrowding in the majors area of the ED at Good Hope and ensure that staff on duty can see and treat patients in a timely way.
The trust must review the operation of rapid assessment of patients to improve its consistency and effectiveness.
The trust must ensure all fire doors and exits are free from clutter.

There were also areas of practice where the trust should take action, and these are identified in the report.

As a result of this, the trust will be subject to regulatory action as requirement notices and a comprehensive inspection will be carried out to confirm this.

Professor Sir Mike Richards

Chief Inspector of Hospitals

The ratings in this report were awarded as part of a pilot scheme to test CQC’s new approach to rating NHS hospitals and services.

Birmingham Heartlands Hospital is the largest of the three hospitals run by the Heart of England NHS Foundation Trust. It provides general and specialist hospital and community care for the people of East Birmingham, Solihull, Sutton Coldfield, Tamworth and South Staffordshire. The hospital has about 700 beds and is a regional centre for thoracic treatment taking patients from across the Midlands. It also has an extensive research department that supports all the services the site provides. We did not inspect the community services.

We inspected this trust as part of our new in-depth hospital inspection programme. This programme is being tested at 18 NHS trusts across England, chosen to represent the variation in hospital care across England. Before the inspection, our ‘Intelligent Monitoring’ system indicated that the Heart of England NHS Foundation Trust was a medium-risk trust. It had a longstanding history of struggling with turnaround times in the accident and emergency (A&E) department. The management team had put initiatives in place to reduce the amount of time people were waiting in A&E but these had yet to have an impact.

This hospital has been inspected six times under the previous inspection methodology. It was inspected three times in 2011 and found to be not meeting the standard on the management of medicines. The next inspections took place in February and June 2012, when the hospital was meeting all inspected standards. The hospital was inspected for the sixth time in January 2013 and was meeting all inspected outcomes.

Before the inspection, we looked at the wide range of information we held about the trust and asked other organisations and four focus groups arranged by volunteer organisations to share their knowledge and experience of it. During the inspection we held three listening events, one near each hospital location, and spoke to more than 60 people who attended. We carried out announced visits to Birmingham Heartlands Hospital between 11 and 14 November 2013. We looked at patient records of personal care or treatment, observed how staff were providing care and talked with patients, carers, family members and staff. We reviewed information that we had asked the trust to provide.

The trust scored below average in the Friends and Family Tests introduced in both the A&E department and for inpatients. However, during the inspection we heard positive feedback from patients who felt that, overall, care was responsive and provided in a sensitive and dignified manner despite caring staff being busy.

In general, we found Birmingham Heartlands Hospital to be responsive to the needs of its population, providing an effective and reasonably safe service that was well-led by senior management. However, there was no effective triage facility for patients within the A&E department, and the speed of decision making and treatment was poor. Within the medical unit, the care given to patients mostly met their needs but the documentation of this care was sometimes poor. The hospital struggled with patient flows as the A&E department continued to see increasing numbers of patients. However, of the three hospitals, Birmingham Heartlands Hospital was more effective than the other hospitals in the trust in managing its patient flow. Staff used ‘JONAH’ boards to ensure that patients were reviewed by a multidisciplinary team and that those who were medically fit for discharge were discharged. This ensured that beds were available for new patients who needed to be admitted.

The trust was aware that there was a shortage of nursing staff, and that had had an impact on the care given to patient. It had decided to make it easier to recruit band 5 nurses and band 2 staff by quicker approval of vacancies and by introducing a rolling programme of recruitment. This was beginning to have an effect in some of the ward areas. However, the full impact of this recruitment programme may not be felt until early 2014. In the meantime, patients and staff said that shortages of nursing staff were preventing people from receiving good treatment and care.

During this inspection we focused on inpatient areas where patients were having surgical procedures.

We spent time on Ward 4 and Ward 12, which are surgical wards. We visited the Admissions Lounge, the Day Surgery Unit and the Discharge Lounge.

We spent time talking with patients and observing their experience of using the service at Birmingham Heartlands Hospital. Our inspection team was supported by an external specialist advisor.

During the course of the day we spoke with 25 patients and two of their relatives. We pathway tracked six patients to look at their experience of the care and support they received. We also spoke with 11 staff from various disciplines.

Patients we spoke with were satisfied with the care they received. Their comments included,

'They treat all patients with equal care and respect.'

'I am quite pleased with the care. Everybody has been really helpful.'

'When I was first in I was very poorly and they were here straightaway. Like everything, it's about priorities. They have always answered the bell.'

We found that staff worked hard to uphold the dignity and promote the privacy of patients.

Patients told us that they had given their consent for the treatment they had received following an explanation from doctors and nurses.

We found there were enough qualified, skilled and experienced staff to meet peoples needs

At the end of the inspection we gave feedback to members of the Trust's Board and other senior managers.

When we inspected Birmingham Heartlands Hospital in August 2011 we found concerns about the safe management of medicines. We undertook this review to check if the trust had taken action to make improvements.

We looked at the action plans and other information the trust has sent us since August 2011.

We did not speak with people using the service at Birmingham Heartlands Hospital during this inspection.

We found that the trust had taken the necessary action to address the concerns raised and make sure medicines were managed safely.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Heartlands Hospital was compliant with the outcomes that we reviewed during our visit to its Accident and Emergency Department in January 2012. The trust is taking action in response to a compliance action in respect of medicines management made following visits to other areas of Heartlands Hospital in August 2011. We will be reviewing these actions in 2012.

We visited Heartlands Hospital's Accident and Emergency (A&E) department on the 9 January 2012 to focus upon the experiences of the care and treatment people received whilst using the department. During our visit to the department we observed that it was a busy day and staff spoken with confirmed that this was the case.

We spent time speaking with people who were using the service. We spoke with nursing, support and medical staff and also with the paramedic staff bringing people into the department by ambulance.

We found that people's dignity and privacy was maintained within the accident and emergency department. For example, the treatment cubicles had curtains that could be drawn and we observed this being done when staff were treating and providing care to people.

People using the service told us they were happy with the quality of care and treatment received which met their medical needs. This included people feeling they had been given enough information about their diagnosis and treatment pathways. Comments made by people included:-

''Done what can for me.''

''All in all not seen a bad nurse.''

''Doctors pleasant.''

We found that the A&E staff were contacted if a person was being brought into the department via an ambulance and would require urgent medical attention. This helped staff to make arrangements for the person's arrival so that they were prepared with the right staff in place to meet the person's medical needs. A person who needed urgent medical treatment was handed over to staff by the ambulance crew within a five minute time framework on the day we visited.

In the maternity areas of the hospital, mothers told us that they had received good care and they felt that the staff were generally helpful. They said that they had been provided with choices throughout the process of birth and felt that these had been respected. When it had not been possible for them to have the experience of their choice, they knew why this was as staff had explained the problem.

Mothers told us that they had confidence in the staff. They had not been left alone for long periods and they had been given advice about breast feeding.

Women confirmed that they had access to interpreters when needed.

They said, 'I'm very happy with the experience', 'I can't say a bad word about it', 'I had everything I wanted', 'The midwives are really helpful'.

One mother told us, 'It's OK but crowded'.

In the discharge lounge, patients told us that the care during their stay was of an acceptable standard. They said that the wards seemed busy and noisy, especially at night. One person told us that the food was 'quite good'. Another said that the nurses were, 'excellent, but rushed off their feet'. Patients who had been in the lounge at lunch time told us that staff had provided them with a choice of drinks and a sandwich.

Patients confirmed that staff had provided them with information about the actions they should take when they were at home and the symptoms they should look out for.

The parents of one child who was being treated in the hospital told us 'We are very happy with the care and medicines are fully explained to us. Discharge to home is well handled'. They said that the respiratory nurse and the consultant were very supportive and approachable. The parents of another child felt the same way and said there were 'no problems'.

Several patients and members of staff made suggestions about how the services could be improved. We passed these on to the trust.

We spoke to 38 patients and relatives across Heartlands, Solihull and Good Hope hospitals. These people were in the Accident and Emergency (A&E) departments and in wards which cater mainly for older people. (Ward 21 at Heartlands, Ward 8 at Solihull and Ward 19 at Good Hope).

Patients across all wards and locations were generally pleased with the standard of service and confirmed that staff seemed to be competent in their roles.

Patients and relatives in A &E departments told us that staff are 'helpful' and 'polite' and the service is good or improving. They said that they had seen staff washing their hands. They thought that the hospital was cleaner than it used to be. Staff had explained what was happening to the patients and they felt that the staff knew what they were doing. Most people said that they had been assessed quickly on arrival. They had been provided with pain relief where they felt it was necessary.

People staying on the wards told us the food was good and they were offered choices. They thought that the wards were clean and told us that the beds are changed daily. They said that the staff looked after them well. They had the impression that staff were very busy.

Some relatives who had returned to the A&E department at Heartlands Hospital, told us they thought that staff should carry out more tests on older patients in order to prevent them from having to come back. Some people said that they would like to be kept better informed about what was happening when they had a long wait. Some people did not have a call system which they could reach easily. This means that they had to wait for a member of staff to pass and then attract their attention.

Archived: Birmingham Heartlands Hospital

All Inspections

06 September 2016 and 18 to 21 October 2016

During an inspection looking at part of the service

Professor Sir Mike Richards

08-11 December 2014

During an inspection looking at part of the service

Professor Sir Mike Richards

8 December 2014

During an inspection of this service

11 November 2013

During an inspection

11-14 November 2013

During a routine inspection

24 January 2013

During a routine inspection

During an inspection looking at part of the service

20 March and 18 September 2012

During a themed inspection looking at Termination of Pregnancy Services

9 January 2012

During an inspection in response to concerns

9 August 2011

During an inspection in response to concerns

6, 7 December 2010

During an inspection in response to concerns