Birmingham Heartlands Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

Not all staff were compliant with safeguarding and PREVENT training (in relation to recognising the threat of terrorism and extremism). The ability to record data for Paediatric Early Warning Scores (PEWS) and sepsis indicators for children and young people on the electronic patient records was still in the development phase. Audits were incomplete for some data and the service could not be assured of the management of sepsis and deteriorating patients. However, the trust had established a working group to review all elements of sepsis management with oversight from one of the senior consultants and experienced staff team.

There were not always safe levels of staffing, and this was the main worry for staff we met. The data provided did not give clear summary evidence as to whether medical and nursing staff levels were safe. Some staff told us they felt the staffing was unsafe on wards at times with the high dependency unit of most concern. However, action was taken to keep the ward safe when there were gaps in the numbers. This included daily monitoring; redeployment of staff from other areas when this was possible; study leave being postponed; and bank staff offered shifts. The trust advised that since our inspection, all staff vacancies had been recruited. Vacancy rates were low and staff retention rates were good.

Some medicines management needed improvement. Annual appraisal reviews needed to be completed for some staff.

However, there was a good culture around learning, people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse, and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

This is the first assessment for this service since the trust was formed in 2018. We rated this key question as requires improvement.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff had a good understanding of how to report incidents, they stated they received feedback from managers, and of any outcomes or learning identified.

Incidents were reviewed for seriousness and themes in order to make improvements if needed or learn when things went wrong. Incidents reported were mostly for no harm predominantly for staffing issues. Between 1 September 2024 and 28 February 2025, neonates had 25 low harm incidents, 3 moderate incidents and 1 severe. The children's wards and paediatric teams reported 11 near misses, 90 low harm and 1 severe incident. The hospital provided evidence to show the severe incident (in the neonatal unit), where a peripheral long line had been accidentally inserted incorrectly, had been through an after-action review (AAR). An AAR was a method of evaluation used when outcomes of an activity or event, had been particularly successful or unsuccessful. Learning had been shared with staff to improve outcomes for this the type of procedure.

The neonatal team produced a regular newsletter called risk governance bulletin (RGB) which included learning from incidents and reviews. They also shared specific learning from cases in the form of a `learning vignette.' The RGB bulletin shared learning from incidents where there had been a delay of inserting umbilical lines and therefore commencing IV fluids and antibiotics for a preterm infant. The bulletin suggested actions to prevent such delays.

We reviewed meeting minutes and actions from the perinatal mortality and child death review panel. This panel met monthly to identify actions and shared learning from these reviews with the departments in the service and across the wider trust. There was evidence of the review of a child death using the patient safety incident investigation process and learning was shared from the outcome of the investigation.

All staff understood their responsibility to be open and honest with patients and their families when things went wrong. Staff were able to explain and give examples of instances of duty of candour which showed they had a good understanding of when this duty needed to be applied. They knew this involved an apology to those affected as well as an investigation into certain adverse events.

The service held daily safety huddles and handovers where incidents were discussed. During our assessment we attended the daily meetings, and they were well attended by staff of all levels.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people moved between different services.

Safety and continuity of care was a priority throughout the care journey of children and young people. There were good systems to support patient pathways. The service had good links with external agencies and community teams. We observed meetings with external partner agencies and managers at the service to assess the needs of a young person and plan their transition to support services after discharge from the ward. We spoke to these partners, and they explained that the partnership working was effective.

Staff had access to support from mental health teams, safeguarding teams and occupational therapy teams. They were able to identify who the designated service leads were for these services and told us they were easily accessible and responsive to requests for support for a child or young person.

The service worked well with other departments in the hospital and with other NHS trusts. Children, young people and their families were involved in discharge plans. The service had a transition lead, who covered the 3 hospital sites. There was evidence of systems being used to support young people from the age of 13 years of age in transition to other services.

Not all training related to safeguarding had been updated to meet trust targets. Safeguarding adults and children level 3 for specialty resident doctors was not meeting compliance at 66.6% against the 90% trust target and needed to be improved. Also, completion rates for PREVENT (in relation to recognising the threat of terrorism and extremism) level 3 training for clinical staff were very low, some as low as 20% and did not meet the trust target.

However, otherwise most other staff, depending on their role, had the level of safeguarding training required. This included safeguarding adults and children, and safeguarding adults and children enhanced training. Each had met the trust's compliance level of 90%. Mental Capacity Act and Deprivation of Liberty Safeguards training was included with the safeguarding training. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve this. Staff concentrated on improving people's lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The service shared concerns quickly and appropriately.

Staff we spoke to demonstrated a good understanding of safeguarding and the different forms of abuse. They could easily identify safeguarding leads and teams and how to get support and report a concern. There was evidence of actions taken to safeguard children and keep them safe from harm.

Patient record systems clearly identified and flagged any safeguarding involvement on the children and young person's records. These were easily identifiable to staff so they would not be missed.

The service monitored all safeguarding referrals and supported staff when they had any questions or queries, or if they were not sure of the next steps. The service also recorded any missed safeguarding referrals. These were discussed at the hospital board meetings every month and the team would take any learning from this to support the staff to help minimise missed safeguarding, although these were infrequent.

The service internal electronic systems and processes did not always help staff and mangers understand and manage risks. The ability to record data for Paediatric Early Warning Scores (PEWS) and sepsis indicators for children and young people on the electronic patient records was still in the development phase. This meant this area had yet to be audited using electronic data (some was reported manually) to provide assurance in the management of sepsis and deteriorating patient records. However, the trust had established a working group to review all elements of sepsis management with oversight from one of the senior consultants and experienced staff team.

Consistency was required in patient monitoring. Records we viewed on wards showed observations for monitoring patients' vital signs and assessing the risk of deteriorating patients were mostly safely undertaken in a timely way. However, the manual audit data for PEWS records from September 2024 to February 2025, showed that in November 2024, the category of PEWS for escalation was 67% completion, 15-minute observations was 33% and observations at 33%. In the months September, October, December 2024, and January 2025, the scores were 100%. However, in February 2025 there was no recorded data for PEWS for escalation, 15-minute observations or general observations. The impact of this was that it was difficult for the nursing staff to have a consistent picture of a patient's health and for the leaders at the service to have oversight of the patient risks and acuity.

Mandatory training for sepsis had been introduced to staff in January 2025. So far, 68% of clinical staff had undertaken the training and 75% of nursing staff 75% against a trust target of 90%. The staff had 12 months to complete the training.

In children's clinical records we reviewed, falls risks were not assessed on paperwork designed in a specific way for children and young people. Paperwork for assessing falls risks in children covered adult parameters and it was a challenge to use this for assessing fall risks for young children. However, we reviewed 15 patient records and falls risk assessments were all complete. The trust reported to us after the inspection how the falls team had worked with the senior paediatric nursing team to develop a specific children's falls assessment which was being brought into use.

The ward was free from ligature risks although the ligature risk assessment was coming up for a three-yearly review having last been updated in May 2022. Following our assessment, the trust arranged for the health and safety team to review the ward with the senior nurse to ensure all ligature risk assessments had been reviewed in accordance with trust policy.

The service worked with children, young people, their families and other community and NHS providers to understand and manage risks by thinking holistically. Staff provided care to meet people's needs that was safe, supportive and enabled people to do the things that mattered to them. We reviewed the records of a young person on the paediatric assessment unit who was a long-term patient. There had been good mental health support, safeguarding records were completed, and there was evidence of psychiatric support. There was good multidisciplinary team working both with internal trust teams and external support agencies. There was a plan for the young person and staff were aware of the plan and the child's likes and dislikes and any situations which could possibly escalate risk.

Children, young people and their families they told us they were given information to help them make decisions about the care and treatment they received on the wards. Children, young people and their parents or carers also told us they felt pain management was well managed.

The service kept records around using restraint if it was needed to manage risks to a patient and staff. Assessments were documented and the type and reason for restraint was recorded. However, ward staff were not trained or permitted to use physical restraint. In circumstances where restraint was needed ward staff requested support from security guards to use physical restraint on children and young people to avoid harm to themselves or others.

Staff had a good understanding of Martha's Rule which was being piloted at the trust. Martha's Rule is a patient safety initiative to enable patients, families, carers, and staff to request a rapid review from a critical care outreach team when they have concerns about a patient's deteriorating condition. However, some families and carers told us they were not aware of the rule, and this had not been explained to them.

The service detected and controlled potential risks in the care environment. Staff made sure equipment, facilities and technology supported the delivery of safe care.

The service had suitable facilities to meet the needs of children and young people. The windows on both wards were safely secured to prevent the risk of falls. All electrical equipment had been tested and labelled to show it was safe to use. Wards and the neonatal unit had weighing scales, baby baths and baby changing units. These were in good condition, had been serviced, and the servicing date was visible on the equipment. Both wards used cots, which were in good condition. The ward had access to sensory toys, ear defenders and a weighted blanket to support any children and young people who had additional sensory or other needs. There was a hoist to help move children and young people safely who were not able to weight bear.

However, the high dependency unit, which comprised of 3 beds and a side room and a desk for staff was small and staff we spoke to told us this area was difficult to work in due to the layout. Leaders told us there was a plan for improving this area.

Resuscitation trolleys were in good condition and in date and daily checks had taken place on both wards. Sharp boxes were stored correctly and were not overfilled. Oxygen tanks were stored securely, clearly labelled with an expiry date, and were in date. Spill kits were located on the ward and neonatal unit within the sluice room.

The service monitored equipment safety alerts. When there were concerns about equipment this information would be shared with staff by email, and within safety huddles.

Entrances were secure and children kept safe. Both ward entrances were locked, and visitors needed to use the intercom to enter after they verified who they were and who they were visiting. There was a security camera at the staff workstations, so staff could check who was at the door. There was additional security for babies in line with required guidance. A security guard at the entrance to the neonatal unit checked identification of visitors and called the unit to inform them of a visitor arrival. All babies were tagged in line with the service abduction policy and protocol.

The service did not always have enough qualified, skilled, and experienced nursing staff to safely care for patients. The data we received when requesting an "uncomplicated review of staffing levels" did not provide clear summary evidence to demonstrate there were safe levels of staffing, particularly for medical posts. In terms of nursing vacancies, the data suggested there were gaps on a number of days in the 6 months from August 2024 to February 2025, but it did not show they were filled to determine if the situation was resolved. It was unclear if there were medical vacancies or gaps in rotas. The hospital provided spreadsheets of medical cover rotas, but no explanation of how to translate these into a clear view of safe cover which met the establishment in terms of numbers and skill mix of doctors. Some staff had not yet had their annual review in certain areas, although the service was compliant overall.

Nursing data provided did not provide clear summary evidence of vacancy rates or whether shifts met safe levels of both numbers of nursing staff and their skill mix. We were provided with spreadsheets for the various wards and units but without a clear summary. However, a review of the spreadsheets determined there were some gaps on the paediatric high dependency unit not filled. Gaps on wards and the neonatal unit were recognised and requests made of bank staff or other staff were redeployed. However, it was difficult to summarise this information to form a clear judgement of safe staffing levels.

The hospital's data around consultant and resident doctor shifts did not provide sufficient evidence to determine if medical staffing levels were safe. We asked the hospital to provide a simple document to show if the numbers of consultants and resident doctors met the establishment numbers. The hospital provided spreadsheets of rotas for consultants and resident doctors without these determining whether there were any vacant shifts or posts unfilled. The data suggested there were gaps, but did not state if these gaps were filled at the time or locum doctors were secured.

However, there were daily meetings to review and oversee the levels of staffing. Staff were redeployed to cover vacancies, stood down from study leave, or vacant shifts went to the bank. Weekly meetings were held with the recruitment team and the dedicated recruitment lead to determine progress around vacancies and escalate any new or upcoming vacancies. Future potential rota gaps were reviewed to make plans to proactively fill the gaps.

The service had worked with a cohort of international nurses through a training and induction programme. New bank staff were given induction days and supernumerary shifts in order to provide safe care with the supervision of the children's team. There had been a drive to support newly qualified nurses to work on the high dependency unit to increase their skills and confidence. Evidence provided suggested only small numbers of staff were leaving the service and if they did, this was mostly for personal reasons or onward promotion, usually within the same trust.

Staff worked together well to provide safe care which met people's individual needs. We saw good working relationships between nursing and medical staff and staff felt supported by managers.

Staff on the paediatric assessment unit told us there was not always a paediatric radiographer available to review scans. However, service leaders told us when we discussed this that there was good access to the radiologist even out of hours and during the weekends in case of emergencies. They told us they would review the case we had highlighted.

The service had mandatory training which was suitable to meet the needs of the children and young people using the service. The trust target for compliance was 90%. The service gave staff 7.5 hours of study leave each year to support them to complete training. Staff received an email from the service education team 3 months before any training was due to expire, with the expectation of staff to book onto training. If training had not been completed a reminder email would be sent to staff requesting completion within 3 weeks. Managers monitored completion rates for training. Medical staff also had a regional teaching day one day a month and took part in research projects.

Staff in the hospital paediatric nursing teams were 94% complaint in their training for paediatric immediate life support and European paediatric advanced life support.

Managers did not always make sure all staff received timely effective supervision and development. Some staff were not up to date with their annual performance review. Staff received appraisals and the service compliance rate overall was 90%, which met the trust target, but there were individual areas not meeting the target. The appraisal rate for clerical staff, medical secretaries and officers was 100%. However, appraisal rates for staff in clinical roles were as low as 50% and needed to be improved.

Security staff were trained to use physical restraint and were able to support a child or young person who may be displaying verbal and physical aggressive behaviours. The security staff at the service were employed by a third-party company who provided their staff with their own specialist training. There were also plans for the security staff to deliver accredited training in conflict management, personal safety, and risk reduction to the service staff in the future.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of spreading infections and shared concerns with appropriate agencies promptly.

There was a good standard of cleaning. All areas and equipment were visibly clean, and equipment was clearly labelled with an `I am clean' sticker, with a date to show when it had last been cleaned. Cleaning schedules clearly identified when rooms and equipment were due to be cleaned and were up to date. The service completed environmental infection prevention audits for both children's wards and the neonatal unit. Between September 2024 and January 2025, compliance ranged from 90% to 100%. We saw evidence of action plans following audits with specific dates for completion. The service had also carried out internal `inspections' in the children's wards and neonatal ward and developed action plans.

There was good identification of possible risks from infection and staff took safety precautions. The ward clearly identified rooms where children or young people were isolating if, for example, if they had been diagnosed with influenza. Staff washed their hands before contact with a child or young person, and also once the treatment had finished. The service completed hand hygiene audits for both the children's wards and the neonatal unit. Between August 2024 and January 2025, the service scored between 90% and 100% compliance every month.

Staff used personal protective equipment and stored waste safely. This included wearing aprons, gloves, and masks and using these when required. There was antibacterial hand gel for visitors and staff to use. Visitors and people using the service also had access to handwashing facilities. The wards had an appropriate storage space for clinical waste, which had a locked door, and containers were emptied on a regular basis.

Medicines were not always stored and managed safely, and not all paper records accurately reflected the route of administration for some drugs. However, the service made sure that medicines and treatments were safe and met children's needs, capacities and preferences.

Medicines were not always stored safely and securely in line with recommended practice. For example, we found an unopened insulin pen stored in a locked medicine trolley. Unopened insulin must be stored in a refrigerator. Although it was immediately placed into the refrigerator it was not known how long it had been stored incorrectly. There was an unlocked medicine cupboard with an increased risk of unauthorised access in the neonatal unit which was immediately locked when we made staff aware. Medicine storage on the high dependency unit was small and cramped which made it less easy to manage. However, we were told the team were looking to make changes to improve and add additional medicine storage. The intravenous (IV) fluid store on ward 16 felt very warm. However, there was no temperature monitoring to be assured the temperature was safe for storage of IV fluids. When we fed this back to senior staff, action was taken immediately, and a thermometer and a checking process was initiated.

Children and young people were supported to receive their prescribed medicines in a way that met their individual needs. Counselling and training were given to support children. For example, training to understand the importance of insulin treatment and how to manage their condition.

Controlled drugs (medicines requiring more control due to their potential for abuse) were stored safely and securely with access restricted to authorised staff. Checks were undertaken and recorded by two staff twice a day which showed they were within date and stock balances were accurate.

Resuscitation medicines required in an emergency followed Resuscitation Council (UK) guidance. Medicines were stored in tamper-evident boxes. Staff recorded daily safety checks on emergency medicines and equipment to ensure they were safe to use.

Medicine room storage and refrigerator temperatures were monitored to ensure the medicines were stored safely. Staff were informed by pharmacy if there were any issues that needed action.

Staff told us there was a dedicated ward pharmacist, and they knew how to contact pharmacy for advice. Pharmacy conducted medicines management and medicines optimisation audits including controlled drugs and safe and secure handling of medicines. Staff said there was a good pharmacy presence and the pharmacy department was available to support them with managing medicine processes such as ordering and receiving medicines. There was good access to pharmacy advice, emergency medicines and critical medicines out of hours.

Pharmacy conducted medicines management and medicines optimisation audits including controlled drugs and safe and secure handling of medicines. Results from audits were followed up by the ward team and discussed at ward huddles.

Electronic medicine administration records were well documented including giving a reason if a medicine had not been administered. However, the route of administration recorded on paper medicine records were not always clear. We reviewed 12 electronic medicine administration records. They were documented with route and time of administration, including recording a reason if a medicine was not given. It was easy to track a patient's medicine administration timeline which helped to ensure that medicines were being given as prescribed. However, on the paper medicines records used in the neonatal unit, doctors had prescribed some medicines to be administered as IV or oral, but the administration records did not record which route had been used. It was therefore not possible to determine whether a medicine had been given IV or orally. Senior staff advised that action would be taken to remind medical staff about safe prescribing and to specify one route. They would be reminded if the route of administration needed to be changed, the prescription must be re-written.

Weights of patients were recorded as standard on all medicine administration records seen which was important for calculating weight-based medicines prescribing. Allergies were highlighted, and medicines could be prescribed safely. Allergy status of patients was routinely recorded on all medicine records seen.

Staff followed systems and processes to prescribe and administer medicines safely. The service had good systems and processes to safely support people with their medicines. Pharmacy staff were actively involved in reviewing people's care and treatment with medicines. They would support with prescribing, de-prescribing, side effect monitoring, medication reviews, and medicines advice. We saw good `pharmacy drug reviews' and recommendations which were clearly highlighted in patients' electronic records to ensure prescribers and nursing staff had access to their advice.

The pharmacy team checked that a patient's medicine history was accurate and up to date. We observed clinical checks being undertaken by clinical pharmacists and updating patient medicine records as part of medicines reconciliation (the process of gathering a complete list of people's prescribed medicines) to ensure people did not go without medicines when admitted to the ward. Any discrepancies or medicine issues were successfully resolved and recorded to ensure the effective continuation of treatment. Medicines for discharge were screened and checked by the pharmacy team for accuracy.

There were effective processes for reviewing antibiotic prescribing which included documenting a reason for the antibiotic choice. A review date after initiation of treatment was highlighted on medicine charts.

There was a clear process for managing and reporting any errors or incidents involving medicines. Staff were able to talk through the process that would be followed if this occurred.

Staff told us they had access to relevant medicine policies, procedures and guidelines.