Queen Elizabeth Hospital Birmingham

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that people and communities had the best possible outcomes because their needs were assessed. We checked people’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

At our last assessment we rated this key question requires improvement. At this assessment, the rating improved to good. Care and treatment was delivered in accordance with evidence-based practice. Staff and teams were working well together to benefit the patient. Consent was managed in accordance with legal requirements. However, there was insufficient evidence to provide assurance that outcomes were monitored and improved.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service planned and delivered people's care and treatment with them, including what was important and mattered to them. Staff did this in line with legislation and current evidence-based good practice and standards.

Staff and the systems they used were up to date with national legislation, current guidance, and required standards. Medical staff told us the Royal College of Emergency Medicine was a source of good practice and guidance alongside the National Institute for Health and Care Excellence (NICE). Nursing staff knew their responsibilities and professional standards of care to which they were required to adhere. Staff were aware of legislation and guidance which protected patients' rights and knew how to apply this in practice. This included patients who were subject to mental health and mental capacity legislation or codes of practice, and people's human rights. Staff were also trained to support people with cognitive impairment and advocate for them.

In our previous report we said the department must ensure all patients had their hydration needs met and there were processes to follow that staff understood. This was a breach of Regulation 14. We found on this assessment that the department had met this breach although the recording of clinical hydration needed to be improved. There had been improvement in the clinical nutrition and hydration of patients either in the department or waiting. People were either given bottled water or able to access fresh water from a drinking fountain. Staff were monitoring patient's nutrition and hydration, although there were gaps in how this was being effectively recorded. However, food was available for people including sandwiches, breakfast foods, drinks rounds and some hot meals in certain areas. However, paramedic staff told us patients who were waiting for long times on ambulances were not able to get food and "surviving on tea and biscuits."

Staff and leaders were encouraged to learn about new and innovative approaches that evidence showed could improve the way their service delivered care. However, staff commented how the pressures on the department from managing so many patients did not leave them always enough time to explore other innovative or emerging approaches to care and treatment.

The service worked well across teams and services to support people, with the exception of some patients who needed more timely support and onward care from mental health services. There was a good multidisciplinary approach to patient care with assessments, planning and coordination being key to effective care and treatment. However, staff were not making sure people's assessments of risks and needs were shared when people moved between different services as some records in the department were incomplete.

Staff had access to the information they needed much of the time to make effective decisions about people's care. This included, if the patient was local or on a shared NHS record, access to a patient's medical history from their GP or other care providers. This was of specific importance to staff when the patient had mental health needs or there were safeguarding or child protection concerns. Otherwise, the existing or known patients' hospitals records flagged when there were concerns the staff needed to be aware of.

There was effective coordination of care between teams in the hospital and wider trust. This extended to care for people who, for example, had a learning disability or dementia. There were specialist trained teams and individuals who made themselves available to the emergency department, staff and patients for support. The vulnerabilities team were established to support those people who were considered as vulnerable for different reasons or had specialist needs. The trust had a lead nurse for dementia who was available for specialist support and regularly visited the department. There were also trained safeguarding staff who could give advice and guidance when there were concerns of abuse or neglect about adults or children.

Staff knew to whom they should delegate patients' care and treatment for specialist input. The emergency department was a major trauma centre and was backed up by a hospital specialising in many major injuries and illnesses. This included 24-hour support every day of the year from surgical trauma teams on standby and all the associated emergency tests and scans required for patients. There were standard operating procedures to indicate to staff to whom certain patients should be referred or to which department. This included surgical and medical specialities, but also GPs, the co-located same day emergency care (SDEC) medical service, and ambulatory care. Staff were able to get specialist advice over the telephone or in person from clinical practitioners, including allied health professionals. There was particular praise for the dedicated physiotherapist in the department for the improvement to patient outcomes they were able to deliver and their proactive work with patients to help get them home.

There was a varied understanding or recognition of the requirements of internal professional standards in multidisciplinary working, but rapid response from teams we contacted. We paged 3 specialty teams from the emergency department and each responded quickly within 1 or 2 minutes. Those we spoke with were aware of internal professional standards (IPS — a description of the principles and times for speciality engagement with urgent and emergency care) although with varied knowledge of their practical application. There was a theme around concerns from speciality teams, particularly with a not uncommon lack of space and safe facilities to work and review patients. This was a similar concern also with the medical staff in the emergency department. However, those resident doctors we spoke with working in the emergency department were not specifically aware of the IPS policy or what it described. When its expectations of speciality teams were described to them, they said they did not recognise this as their experience. In the 2024 NHS Staff Survey, just 29.4% of staff who responded from the emergency department (51 staff) said they felt teams worked well together to achieve objectives.

However, as with many patients, due to ward-bed capacity being often full, there were unacceptable waits for onward care for those patients with mental ill-health. As we have highlighted in the safe section above, there was a lack of parallel assessment of patients presenting with both mental and physical health needs, which did not follow the guidance of the Royal College of Emergency Medicine mental health toolkit and the National Confidential Enquiry for Patient Outcomes and Death `Treat as One' report. Staff reported how a psychiatric assessment for a young patient who had been in the department for a number of days would not be happening by the local mental health services until the patient was medically fit. Terms such as "medically fit" were not to be used to delay mental health reviews.

There was insufficient evidence to show the service routinely monitored people's care and treatment to continuously improve it, or if it was monitored, it was not being effectively reported. Staff did not always ensure evidence showed outcomes were positive and consistent, or they met both clinical expectations and the expectations of people themselves.

As we have reported in our section below on governance, metrics were not presented for assurance and to report on clinical outcomes for patients. For example, 1 area of concern which was noted in governance papers and trust board reports was with a probable rise in pressure ulcers for patients experiencing long delays in the department. However, there was limited commentary on the cause of the avoidable harm and only a comment about the arrival of new mattresses as a solution. Outcomes of patients being given life-saving treatment or intervention were not reported or celebrated for their success. Avoidable harm was not reported as being investigated for sources of learning around patient outcomes to improve the service.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment. There were practices carried out by clinical staff to ensure people gave valid consent to any care of treatment. Most consent was obtained verbally or by clear indication, which was in line with legal requirements.

Staff understood the importance of people being able to fully understand what they were consenting for and the importance of obtaining consent before care or treatment was delivered. We heard consent conversations taking place between staff and patients, and all were conducted as they should be. Most staff were aware of legislation when it came to a patient who was not able to give their valid consent. Staff knew if the patient was not conscious then they had a duty to act to save their life or provide the right care and treatment. Reasons for the treatment being necessary would be explained to the patient when they regained consciousness and were judged as able to understand.

Staff knew how people who did not have the mental capacity at the time to give valid consent should be treated differently. Most staff knew consent could not be provided by another person unless they had a lasting power of attorney for the patient. In those cases where the patient did not have capacity or an attorney, staff knew they needed a multidisciplinary approach to treating the patient where a decision was taken in the patient’s best interests. In these circumstances, staff knew they had a duty to endeavour to involve the patient’s relatives or friends, or an advocate for the patient, if possible, in any decision taken.

Most staff were aware of the legal position around consent from children or young people under the age of 18. Staff mostly recognised how a child or young person could give their consent if they were assessed as mature enough to do so regardless of age. The service did not treat children under the age of 16 as a rule, but this would apply to a young person between 16 and 18 years of age. Also, there were circumstances where a younger person might be treated if there was an emergency and staff were unable to ascertain the child’s actual age at the time.

People were able to take decisions which clinical professionals might consider to be not in their best interests or could result in their death. Patients who had full capacity to make their own decisions must have their decision respected, as long as all the information had been given to them along with the risks and benefits. However, staff were clear that patients were not able to take decisions which put others at risk of harm. People were also able to change their mind if they wished, and doctors said they would always check if a patient was still giving consent if a certain amount of time had passed since consent was obtained. This would depend on the patient and the procedure being undertaken. For example, staff in the X-ray department said they always asked the patient for their consent, even if they had indicated before or told another medical professional they were willing to undertake the examination.