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Queen Elizabeth Hospital Birmingham Good

Inspection Summary


Overall summary & rating

Good

Updated 13 February 2019

Our rating of services stayed the same. We rated it them as good

For an overview of our findings at this inspection please see overall summary above.

Inspection areas

Safe

Good

Updated 13 February 2019

Effective

Good

Updated 13 February 2019

Caring

Good

Updated 13 February 2019

Responsive

Good

Updated 13 February 2019

Well-led

Good

Updated 13 February 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 13 February 2019

Our rating of this service stayed the same. We rated it as good because:

  • The safeguarding team and senior ward staff maintained consistent standards of safeguarding. Teams thoroughly investigated safeguarding incidents and implemented learning that improved practice and patient safety.
  • Standards of infection control practice, such as hand hygiene, were consistently good during our inspection. Infection control was audited and monitored by a dedicated team and housekeepers with extended training.
  • A range of systems and strategies were in place to assess patient risk. This included electronic deterioration monitoring systems, out of hours senior medical cover and advanced training for staff in managing acutely unwell patients.
  • Antimicrobial stewardship and sepsis programmes were well established with a rolling, comprehensive programme of audits and substantive training programmes for staff and doctors.
  • Shared learning was a significant focus for staff and there was extensive evidence of detailed, multidisciplinary investigations of incidents and complaints that led to improved practice and training.
  • Staff delivered care and treatment in line with national and international standards and clinical guidance. Systems were in place to ensure this remained current and specialities were demonstrably motivated to achieve accreditation status with professional bodies.
  • Medical care services had a significant research profile and staff were supported to develop projects that placed them on the leading edge of current knowledge in their specialty.
  • Allied health professionals were highly active in audit, benchmarking and research and led numerous projects that positively impacted medical care services. One project, relating to dietary management in radiotherapy patients, resulted in 88 saved bed days.
  • Pain services were multidisciplinary, comprehensive and led by audit and research benchmarking.
  • Audits to drive service improvement and to improve understanding of patient behaviour were embedded across medical specialties. Staff were passionate and motivated in the development of audit plans, such as in recent examples of a wide-ranging falls review project and a health promotion focus on alcohol and tobacco reduction.
  • Multidisciplinary specialist teams facilitated a wide range of education, learning and development opportunities for staff. This focused on future service sustainability, the development of a highly specialised in-house workforce and the retention of staff through internal development.
  • Staff demonstrated resourcefulness and resilience when managing highly complex situations that involved multiple agencies and organisations.
  • There was extensive evidence of staff going beyond their responsibilities to deliver individualised, compassionate care that made a significant difference to patients and others living in challenging circumstances.
  • Teams had developed processes and communication strategies to increase the involvement of patients in their care planning. This was reflected in new handover processes, consistently good documentation of conversations with patients in medical records and positive results in the NHS Services Seven Days a Week Forum's seven-day services priority standards for patient involvement.
  • Staff continually looked for new ways to further meet patients’ needs to improve their experience and ensure the service maintained momentum.
  • Staff were dedicated to safely reducing the length of stay for inpatients, reducing delayed discharges and improving flow and capacity. Multiple innovative projects and trials contributed to this, reflecting efforts from different groups of staff, including clinical teams, allied health professionals and divisional groups.
  • Ward teams and specialties were responsive to learning from complaints and implemented changes and improvements as a result of learning.
  • Divisional governance and leadership structures were clearly embedded in the operation of clinical services and leadership teams had developed effective systems of quality and performance improvement.

However, we also found areas for improvement:

  • There were significant shortfalls in some elements of medicines management, including in storage and disposal, that had not been addressed by pharmacy teams.
  • Staff described their greatest challenge and cause of staff as persistent shortages in nursing teams.

Critical care

Outstanding

Updated 15 May 2015

Critical care services were found to be outstanding, providing effective treatment with excellent leadership.

There were sufficient, appropriately skilled and experienced medical and nursing staff available within critical care units.

Critical care services were obtaining excellent results for patients who received treatment that was based on national guidelines. The hospital had seven-day working and outstanding, effective multidisciplinary working which had a positive impact on patient care and recovery. Critical care staff were caring and compassionate.

Bed capacity of critical care services was not generally a concern, although the unit had experienced delays in discharging patients to other wards. Staff remained with patients if they were moved within the unit to maintain consistency.

The team supported rehabilitation of patients well.

The leadership of critical care was outstanding. Staff reported that nursing and medical leaders were supportive and encouraged innovation. Staff were aware of and committed to the trust’s vision and demonstrated commitment to its objectives and values. Staff were proud of the standard of care they provided and said that their achievements were recognised by their senior managers.

End of life care

Good

Updated 15 May 2015

Overall we rated end of life care services as ‘good’. Staff provided compassionate care for patients. Services were very responsive to patients’ individual needs and those of their families and next of kin. We saw and heard about many examples where practical, emotional and spiritual needs were considered and met.

Although the trust did not take part in national audits, data from their own survey showed that relatives were positive about the quality of care and their experience of the service. We observed comprehensive and dynamic multidisciplinary working taking place, which covered all aspects of care. The trust’s electronic information system ensured that do not attempt cardio-pulmonary resuscitation (DNACPR) records were managed safely. Medicines were prescribed and administered in a safe way and there was guidance available for anticipatory medications.

At the time of our inspection, the service was on the cusp of significant change which the trust believed would enhance and improve the service. It was clear that leaders of end of life care services worked collaboratively across the hospital and their commitment to delivering a good quality service was evident.

HIV and sexual health services

Good

Updated 15 May 2015

Staff received mandatory and specialist training to meet patients’ needs. Staff were knowledgeable about incident reporting and received feedback on lessons learned Infection control procedures were being followed. Medicines were being stored appropriately.

Evidence-based care was provided by competent staff and in accordance with national guidelines. An annual schedule of national and local audits took place to monitor the effectiveness of treatment. The results were regularly monitored within governance meetings and reported back to staff to implement changes to practice where required.

We found the sexual health services to be caring. Patients spoke highly of the staff and the service they had received. Patients were treated with dignity and respect. Patients felt supported and were given clear explanations about their care and treatment.

There was flexible access to clinics with booked and walk-in appointments. Early morning and evening appointments were available to accommodate people who worked during the day. Clinics were situated across Birmingham to provide more local services.

 Some nursing staff who had previously worked in sexual and reproductive health service felt unsupported, undermined and not valued by management. However, there was a disparity between staff groups as medical staff and nursing staff who had previously worked in genitourinary medicine did feel well-supported. Medical staff who previously worked in sexual and reproductive health service felt the same. We acknowledged that this was a newly integrated service but improvements were needed to ensure that all staff felt supported.

Surgery

Good

Updated 13 February 2019

Our rating of this service stayed the same. We rated it as good because:

  • We rated safe, effective, caring, responsive and well-led as good.
  • The service had innovative and leading practices that improved the experience and outcomes for patients.
  • The service was a national lead in several specialities and good practice for example, major incident planning.
  • The service had enough staff, who had completed required training. Staff were supported by managers and had annual appraisals.
  • In theatres the environment was clean, tidy and equipment was readily available, clean and well maintained.
  • The service had thorough pre-assessment screening for patients requiring surgery that considered peoples individual needs.
  • The service stored and administered medicines well.
  • Staff worked well in multidisciplinary teams and provided compassionate, appropriate and individualised care to ensure good outcomes for patients.
  • Managers supported staff, promoted learning from incidents, concerns and complaints and used available information to improve to the service.

However:

  • Local Safety Standards for Invasive Procedures (LocSSIPs) for theatres that should have been in place were still in development.
  • In theatres we saw an instance where fridge temperatures were not recorded and an instance where checks on resuscitation equipment were not recorded.
  • We saw two instances in theatres where staff had not followed an aspect of the appropriate surgical safety checklists.

Urgent and emergency services

Good

Updated 13 February 2019

Our rating of this service stayed the same. We rated it as good because:

  • Senior staff implemented support processes and systems to improve staff access to mandatory training. The completion of safeguarding training had improved as a result although fire safety training remained an on-going challenge.
  • Standards of infection prevention and control were consistently good and staff achieved highly in audits in this area.
  • Processes, systems and care frameworks were in place to manage risks to patients. This included for patients who presented frequently in the department and those with immediate mental health needs, such as suicidal intent.
  • Nursing staff levels were consistent and both the ED and CDU demonstrated successful rolling recruitment drives. Nurse turnover was less than 2%, which were significantly better than the other hospitals in the trust.
  • A wide range of medical and specialist professionals supported the medical team and nurses and provided substantial additional care and treatment options for patients as well as professional development opportunities for staff.
  • Patients, relatives and carers said they felt staff were kind, compassionate and attentive. They said they were well informed and felt able to ask questions at any time.
  • Services were developed based on the needs of the local population and their health trends. Partnerships were established with a range of community, social care and specialist organisations to plan services and to reduce unnecessary emergency department attendances.
  • Clinicians had worked with colleagues across the hospital to establish care pathways to improve patient access to specialist care.
  • A culture of continual learning and supporting staff to advance was embedded in every aspect of service delivery and development.

However:

  • The ED did not meet minimum Royal College of Emergency Medicine (RCEM) standards for consultant cover and had 17.4 whole time equivalent (WTE) vacancies, which was a shortfall of 19%.
  • Medicines management processes were inconsistent in some measures. This included management of refrigerated medicines.
  • Triage of patients in the department did not always meet the Royal College of Emergency Medicine (RCEM) standards to be undertaken within 15 minutes of arrival.
  • Oversight of the maintenance and safety checks of emergency equipment was inconsistent at both a local level and a trust level.
  • The hospital did not have access to a ‘high risk’ room suitable for conducting mental health assessments. This meant patients attending the emergency department as a result of a mental health crisis, such as self-harm or a suicide attempt, were unable to be assessed and reviewed in a space which was free from objects or fittings that the patient could use to harm themselves. Although the CDU mitigated this risk to some extent with two anti-ligature rooms, these did not fully comply with best practice in risk reduction.
  • Although nurse staffing levels were consistent, from April 2017 to March 2018 7850 shifts went uncovered.
  • Performance in national RCEM audits was highly variable and in some audits, including the 2016/17 consultant sign-off audit, the hospital did not meet any of the national standards.

Outpatients

Good

Updated 13 February 2019

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with our previous rating.

We rated it as good because:

  • Staff were clear on how to report incidents and received feedback from investigations. The service had a clear process to investigate and learn from incidents through root cause analysis. It communicated any findings across the services and to patients and families in line with the Duty of Candour
  • Arrangements were in place to minimise risk to patients and these were supported by policies and procedures. Risks to outpatients awaiting a follow up appointment were appropriately managed. Nurses and clinicians had a high level of awareness of how to care for vulnerable patients. The service was delivering an enhanced level of safeguarding training to level 3 to ensure all nursing staff were trained to safeguard children
  • Since our last inspection, governance, risk management and performance management in outpatients and cancer service had improved. Task and finish groups addressed specific improvement projects in outpatient services, and risk and quality were managed at specialty and divisional level.
  • Action planning to drive performance had improved since our last inspection. Outpatients and cancer specialties developed action plans and trajectories to address underperformance and recover backlogs. They recruited to areas where they lacked capacity and used locums where necessary. There were specialty level, divisional level and corporate meetings to monitor performance and progress on action plans in outpatients and cancer services
  • Patient list monitoring processes were in place, supported by technology which enabled staff and leaders to clearly identify where patients were on their treatment pathway
  • Access and flow in the service improved since our last inspection. It had the technology to monitor patients waiting times in clinics and investigated the root cause when patients had waited more than 60 minutes. This led to a problem-solving approach to delays, and shorter wait times
  • The service had tailored consultation times to the needs of outpatients with complex conditions. It had increased the facilities available for them by moving more specialist clinics to other buildings, in response to the overcrowding we found in our last inspection. This allowed more complex outpatients to have longer consultations. Specialities also reviewed templates and consultation times within the Queen Elizabeth outpatient clinics and developed action plans to make improvements
  • Leadership had strengthened around performance improvement. Meetings at appropriate levels within specialties and weekly RTT and RCA assurance meetings meant that leaders took decisions to improve performance, requested action plans and monitored them
  • Outpatient specialities responded to local needs and were adapting services to meet increasing demand. The services responded to unmet need and this was leading to new types of clinic. Specialties were working in partnership with HGS and commissioners to deliver new services in the community, and using new technology such as virtual clinics
  • Outpatient specialties demonstrated a strong approach to working with other services to deliver joined-up holistic treatment for patients. The cancer service had 24 multidisciplinary teams which meant they tailored treatment to the individual patient as much as possible. Highly trained clinical nurse specialists ran clinics which gave outpatients practical support and increased access to services
  • The service ensured that unqualified and qualified nursing staff were competent to work in clinics. Staff were encouraged to develop their skills and this was supported by the outpatient clinical educator role, and mentoring from experienced nurses. The outpatient service did not use agency nursing staff, instead preferring to use in-house bank staff with the appropriate level of training if there was a staff shortage
  • Clinicians and nurse were kind and reassuring with outpatients. They displayed understanding of the needs of older patients, people living with dementia and learning difficulties
  • The service supported outpatients well. Clinical nurse specialists provided good emotional support to patients with life changing diagnoses in outpatients and cancer services. For example, an Eye Clinic Liaison Officer gave practical help to patients adjusting to sight loss and clinical nurse specialists talked through diagnoses with cancer patients
  • The service adapted to the needs of some patients for example, there were bariatric chairs in waiting areas and access to interpreting services for those who did not speak English as a first language. Specialist liver nurses visited liver clinic patients in prisons.
  • Many of the outpatients and cancer services were innovative. For example, the cancer service was active in the 100,000 Genomes project and had tumour boards in place. The ophthalmology specialty was nominated in the UK Ophthalmology Awards for its Uveitis service.

However:

  • For the period July 2017 to June 2018 the trust performed worse than the 85% operational standard with a rate of 76.0% for patients receiving their first treatment within 62 days of an urgent GP referral. The England average for this time was 82.1%. Trust performance was 79.6% in August 2018. At this hospital 65.3% of patients referred by their GPs were treated within 62 days
  • The service did not have a systematic approach to identifying and planning for the access and communication needs of diverse groups of patients. For example, it was not always easy for older people to find their way to the appropriate waiting area because there was no visually accessible internal plan of the hospital provided with the appointment letter
  • Procedures around checking resuscitation trolleys and fridges were not sufficiently embedded and we found examples of non-compliance
  • Flow did not always work smoothly for patients. The queuing system before arrival at fracture clinic meant that frail or injured outpatients had to stand for up to 20 minutes before proceeding to x-ray
  • Patient privacy was not always maintained. A drugs storage room doubled as a room where staff took blood samples from patients and this process was interrupted by members of staff entering to remove supplies
  • Services did not work seven days a week, although some clinics offered appointments at the weekend or during the evening
Other CQC inspections of services

Community & mental health inspection reports for Queen Elizabeth Hospital Birmingham can be found at University Hospitals Birmingham NHS Foundation Trust.