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Archived: Birmingham Heartlands Hospital Requires improvement

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Inspection Summary


Overall summary & rating

Requires improvement

Updated 2 August 2017

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

Inspection areas

Safe

Inadequate

Updated 2 August 2017

Effective

Requires improvement

Updated 2 August 2017

Caring

Requires improvement

Updated 2 August 2017

Responsive

Requires improvement

Updated 2 August 2017

Well-led

Requires improvement

Updated 2 August 2017

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 2 August 2017

We rated the service overall as requires improvement because:

  • Nursing and medical vacancies were high and planned staffing levels were not always being met.

  • Infection control measures were not consistently applied and we saw poor levels of hand hygiene.

  • Patients experienced delayed discharges not only due to lack of care in the community, but to poor discharge management and arrangements. This included insufficient patient transport (operated by another provider) and porter provision.

  • There were a number of medical outliers: patients who were admitted to other wards as there was no appropriate medical bed free. Medical reviews of these patients were on some occasions being missed.

However:

  • The trust had a rolling recruitment drive both nationally and internationally and were recruiting with success.

Services for children & young people

Good

Updated 14 January 2014

Children’s safeguarding procedures were robust and had been improved in response to findings from a serious case review. Assessments of patients’ needs were undertaken on admission by both nursing and medical staff, and care and treatment were delivered effectively by caring staff. There was a strong management presence in the form of the head of nursing, matron and supervisory ward sisters or managers. There was evidence of regular senior meetings and completion of audits to monitor the quality of service provided. There was also evidence of learning and improving as a result of incidents that had occurred. However, the hospital was not responsive to the management of children and adolescents or young people with mental health needs. This was because staff had received no mental health training, and there were no policies (other than one for suicidal patients) or pathways in place to ensure consistency in practice. Risk assessments were undertaken but were not robust enough to minimise the potential risks to these patients.

Critical care

Good

Updated 2 August 2017

We rated this service as good because:

  • Staff were caring and compassionate.

  • There were sufficient and competent medical and nursing staff available to provide care and treatment for patients seven days a week. However the availability of other health professionals such as physiotherapists did not meet intensive care core standards.

  • The leadership, governance and culture of critical care services promoted the delivery of safe, high quality person-centred care.

However we also saw that:

  • The critical care units (ITU and HDU) did not meet the needs of a modern service. There were no toilet or bathroom facilities within either ITU and HDU.

  • Heartlands Hospital is a regional infection diseases centre. There were three side rooms within the intensive care unit (none within the high dependency unit), which could be used for critically ill infective patients. However, none had modern facilities (negative pressure to contain any bacteria within the room) to reduce the risk of, cross infection to other patients.

End of life care

Good

Updated 14 January 2014

Patients received safe end of life care. They had support to make decisions about their care and staff working in the service were experienced, knowledgeable and passionate about providing good care outcomes for patients. Patients and their families had positive views about the end of life service. The hospital had worked hard to meet the needs of its local ethnic population and to ensure that the religious and cultural needs of people at the end of their life were met in a timely and sensitive way.

Maternity and gynaecology

Requires improvement

Updated 1 June 2015

Safer staffing information were not visible for women and visitors to the ward. The midwife to birth ratio was worse that the recommended average. Current arrangements for the cover of a second obstetrics theatre needed to be improved. The hospital did have an onsite consultant 24 hours a day, 7 days a week which was meeting national guidelines.

Staff involvement in future planning of service delivery was lacking. We also noted that facilities and specific arrangements for people with disabilities were not robust.

There was a lack of visible leadership and the staff were unclear about the maternity strategy and felt powerless to affect service development and delivery. Staff worked well in their teams, but there was little interdepartmental co-operation.

Outpatients and diagnostic imaging

Good

Updated 2 August 2017

We rated this service as good because:

  • Staff were encouraged to report incidents of all kinds and all staff we spoke with were aware of how to do so.

  • Staff demonstrated good knowledge and understanding of safeguarding and were able to give recent examples of how they had followed protocols.

  • The departments were clean and logs showed that they were regularly cleaned and checked.

  • Medicines were stored appropriately and checks of controlled drugs completed daily.

  • Patient records were clear, legible, up to date and available for clinics.

  • We saw evidence of strong multidisciplinary working across departments, divisions and grades of staff.

  • Policies and protocols were based upon national guidance and reviewed and updated appropriately.

  • The World Health Organisation (WHO) checklist was used and practice seemed to be embedded.

  • We saw effective pain relief used for patients receiving treatment.

  • Staff told us they had effective access to information that enabled them to provide care and treatment to patients.

  • We saw that staff provided compassionate care for patients and respected the privacy and dignity of those attending the departments.

  • Patients and their family members or carers were fully involved in planning and choosing their care and treatment.

  • Patients gave positive feedback about the staff as being supportive and caring.

  • The breast clinic offered a ‘one stop’ service which patients could access quickly and receive results and treatment if possible on the same day.

  • Clinics ran during the evenings and weekends which gave patients choice of appointments and was working to reduce waiting times.

  • Staff displayed the trust values and understood what these were.

  • We saw and staff described that in most areas of the departments there was strong leadership in place and senior managers felt well supported by the executive team also.

However:

  • Patient records were left out on open trolleys which meant they were accessible and visible for other patients to see so did not ensure confidentiality was being maintained.

  • A piece of equipment in the ophthalmology department was three months overdue for servicing. This machine was still in use and therefore could be unsafe for patients.

  • Staff told us that clinics were often overbooked, appointments were often not long enough for patients and so clinics would over run and be held later that arranged. This impacted upon patients waiting times and staff had concerns that appointments may seem rushed.

  • The controlled drugs documentation in the ophthalmology department indicated that use of these was not always witnessed and/or signed out appropriately.

Surgery

Requires improvement

Updated 2 August 2017

We rated this service as requires improvement because:

  • BHH reported three never events from August 2015 to July 2016. Never Events are serious incidents that are wholly preventable as guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers. Two of these incidents related to procedures which were carried out on the wrong site of the patient’s body, indicating that learning from one incident did not take place in a timely manner.

  • Medicines were not stored safely and in line with requirements. We found some patient’s controlled medicines were past their expiry date, medicines which should have been protected from the light were not, and the temperature of the refrigerators used to store medicines exceeded recommended limits at times.

  • Patients with a fractured hip waited for up to 12 hours for their pressure relieving mattresses..

  • Patients experienced delays in their journey from admission to discharge. This included delays in returning from the operating theatres to the wards due to a lack of available beds on the surgical wards.

  • Delays in discharging patients occurred due to waits for medicines to take home (TTOs)

  • Services were not always responsive to the needs of individual patients and those who were vulnerable. Staff did not always use the trust’s translation service and instead used patients’ families and friends to interpret for them when discussing patient care. There was limited provision for patients living with dementia or a learning disability.

  • Governance structures were in place but were not fully embedded. Risks were not always identified and managed appropriately.

  • Staff described a blame culture when being held to account for incidents during root cause analysis (RCA) executive forum meetings.

However, we also saw:

  • There was a good incident reporting culture. Managers shared learning from incidents with staff through newsletters, ward meetings, handovers, between teams and staff notice boards.

Urgent and emergency services

Requires improvement

Updated 2 August 2017

We rated this service overall as requires improvement;

  • When we carried out the inspection we found there were a number of safety issues. In particular the level of overcrowding and use of the corridors to house patients on trolleys.

  • There were risks around timely assessment and handover and the standard of care that staff were able to give because of this.

  • There were mixed levels of mandatory training and infection control measures.

  • Pain relief was poor for patients we received mixed feedback from patients and families.

  • There were significant issues with delays and flow of patients through the department.

  • There was poor morale amongst staff and little patient engagement.

However;

  • Staff training and education, stroke management, multidisciplinary working and working with other stakeholders was of a good standard.

  • Research was evident and results were used to inform improvement in care.

Medical care (including older people’s care)

Requires improvement

Updated 1 June 2015