Birmingham Heartlands Hospital

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We reviewed the governance, management and sustainability quality statement from the well-led key question. As this assessment was based on risk, we did not complete enough quality statements to re-rate the whole key question, well-led therefore remained good.

There were governance processes in place for the service, however these were not always deemed to be effective and consistent. Staff were aware of their roles and responsibilities and who they were accountable for. The main risk in surgery was staffing levels and whilst there was a number of vacancies across the service, a large proportion of these vacancies had been recruited into.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff told us there were governance, management and accountability arrangements in place, and that they understood their role and responsibilities, what they were accountable for, and to whom. However, further discussions and reviewing of information to triangulate our findings found the arrangements in place were not always effective and consistent.

We were told the clinical decision groups had quality and safety committee meetings where they reviewed incidents, complaints, audits. Matron fed back key messages from the quality and safety committee meetings to the ward managers who then implemented changes as needed. Managers told us about improvements they had made following feedback from governance meetings. For example, in September 2023, ward 7 had poor compliance with the completion of risk assessment paperwork within 6 hours of a patient being admitted to the ward. The manager had talked about this within the safety huddle, spoken to individuals and completed an analysis of the data. They found that the poor compliance was often on the night shifts and therefore wrote a letter to the night staff to raise awareness and improve compliance. They had seen the overall compliance increase following this from 20% in September 2023 to above 70% in February 2024.

Staff told us they received feedback from audits that were undertaken. We observed a changes meeting on Ward 7 where the nurses had an update following the doctor’s rounds. The nurse discussed the patients but also discussed a recent controlled drugs audit which scored 92% and the improvements needed to increase compliance. We also saw audits were discussed in team meetings and huddles and documented on notice boards for staff to see. During the onsite assessment, staff told us there had been work completed to drive improvements and share learning in relation to compliance with documentation. However onsite evidence collected identified there was still poor compliance.

The surgical service had a clear management structure. It was managed by an associate director of nursing and was split into 3 clinical division groups, each with their own matron. Each ward was managed by a ward manager.

The service had a clear governance structure with various committees. There were monthly governance meetings within each clinical division group which fed into a quarterly clinical governance meeting. We reviewed 3 sets of clinical divisional group meetings that showed there were processes in place to review risks within the service. However these processes were not as effective as they could be. The evidence we reviewed was brief and there was minimal detail about the discussion of risks despite identifying there were a number of risks which required work on them but were yet to receive associated action plans. We also found there were minimal details in relation to audit outcomes and incident information.

Additional information provided by the trust identified the trust had undergone a change in the way in which each location was managed and this impacted the governance processes. There had been changes to the processes in place to oversee the risks for each location.

Learning was shared with staff but the level of detail varied across different wards. Managers used a number of avenues to communicate with staff including team meetings, changes meetings, huddles and newsletters. Both areas we visited also told us they used an encrypted social media application for communication. We reviewed ward meeting minutes for ward 4 which kept staff informed. However, other minutes provided after the assessment were not as comprehensive as these and therefore raised concerns over the consistency across the service.

Clinical dashboard data was discussed monthly, however only 2 areas achieving targets were discussed. This did not identify how the areas which were not meeting their targets were managed or what action was taken to drive improvements.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.