Birmingham Heartlands Hospital

On this page

• 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 looked for evidence of an inclusive and positive culture of continuous learning and improvement, based on meeting the needs of people who used services and wider communities. Leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

There was a shared direction and culture managed by capable, compassionate and inclusive leaders. Staff felt safe to speak up. There was good governance and close working with partners and the community.

This is the first assessment for this service since the trust was formed in 2018.Well led is rated as good. This meant children and young people’s needs were met through good organisation and delivery.

We have not awarded this service a score for Well-led.

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

There was a developing strategy for the children’s service. The trust strategy had been published, and the Birmingham Heartlands Hospital strategy linked with this had been consulted on and was being finalised. Once this had been approved, the children and young people’s service would produce its strategy in line with the other services. The strategy currently used for children and young people reflected that of the local authority’s Children and Young Persons’ Partnership Board.

There was an overview of services provided for children and young people for all sites including at Birmingham Heartlands Hospital. This described how the trust planned to further reduce inequalities, hear from children and young people, prepare young people for adulthood, and support safeguarding and mental health.

The service had a shared vision and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding the challenges and needs of people and their communities.

There was a strong patient-focused culture. Staff told us they felt supported by ward managers and matrons, and they felt there was good team working within the service. However, staff did say their morale was low at times when they were short of staff.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience, and credibility to lead effectively. They did so with integrity, openness, and honesty.

There was a clear management structure with no vacancies at senior level. Staff were given the opportunity to develop leadership qualities and develop their roles. All matrons, managers and all staff knew their job roles and understood the accountability requirements.

Leaders were visible and approachable, led by example and modelled inclusive behaviours. Staff told us ward managers and matrons were supportive, and they could speak to them regarding any concerns they had. Notes from staff meetings, where managers would raise any concerns they had in relation to staff practices, showed how they could bring improvement.

Leaders were knowledgeable about issues and priorities for the quality of the service and were able to access support for their own roles. They were alert to any examples of poor culture that might affect the quality of care for children and young people or have a detrimental impact on staff.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff were encouraged to speak up and to raise concerns. Leaders promoted the value of speaking up. The hospital had a dedicated Freedom to Speak Up Guardian. The Guardian's role was to support workers to speak up when they felt they were unable to in other ways. Information about speaking up was easily accessible on the trust's intranet. The staff had a good understanding of what the Guardian's role was. Staff told us they would approach them if they felt it was needed but would generally approach their line manager in the first instance for support and guidance.

There was a good culture of speaking up where staff felt safe to raise concerns without fear of detriment. Concerns were handled sensitively and confidentially and mindful of people's rights and responsibilities.

The service valued diversity in their workforce. Staff worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The service had a diverse staff team and staff felt there was good teamwork and there was a positive culture around equality, diversity and inclusion.

There was a commitment to supporting equality, diversity and inclusion through peer-to-peer networks. The trust had several staff network groups to support equality, diversity and inclusion run by enthusiastic staff.

The trust completed equality, diversity, and inclusion reports, including the headline reports for the Workforce Race Equality Standard and the Workforce Disability Equality Standard. These were in the process of having their data extracted at hospital level so the team in charge could make more local decisions about diversity and improving equality for staff.

The service leaders had clear responsibilities, roles, systems of accountability and mostly good governance. Staff used these to manage and deliver good quality, sustainable care, treatment, and support. Staff acted on the best information about risk, performance, and outcomes, and shared this securely with others when appropriate.

Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss, and learn from the performance of the service.

However, staff told us there was no system to audit the implementation or quality of hospital passports. They said the mental health hospital passports were not mandatory but should be offered to everyone if there were concerns and it was up to the patient or their carer if they chose to complete it.

The matron and clinical services lead were responsible for governance. An additional need had been recognised for nursing support to governance and an additional post had been created for both neonates and paediatrics. The role in paediatrics was being recruited to.

There was a range of audits used to understand care and treatment and the quality and safety of how it was provided. These audits were well documented and completed at different frequencies as pre-determined by the audit schedule. However, the service did not complete audits for the monitoring of sepsis or capture electronic data as yet for Paediatric Early Warning Scores, although these were both in development.

The managers operated effective governance processes throughout the service and with partner organisations. They had structures and systems of accountability, so all levels of the management knew and understood their roles and responsibilities.

The trust had a risk management system with 2 risk registers, 1 for children's services and 1 for the neonatal service. The risks were dated from when they had been identified, showed if they had been approved or waiting approval, and how the service was mitigating the risks.

There were a range of meetings to cover governance, quality and safety for both children's and neonatal services. Minutes recorded what was on the agenda and covered a range of key topics. This included, for example, staff vacancies, infection control, health and safety, and mandatory training compliance. It also covered patients' experience and feedback. There was an education update in which any incidents were discussed to determine how learning and changes were to be implemented. In the children's ward meeting, the team discussed pharmacy concerns, audits, risks, and culture concerns on the ward. The team discussed how they were going to address arising risks and issues.

Action plans were assessed for their progress. They showed the issue raised, the assurance received, the action and timescale of when this was to be met.

The service reviewed hospital data for learning from deaths, and a review was undertaken every 3 months. The service had a process for escalating reviews of deaths and were involved with the morbidity and mortality reviews.

The service understood the duty to collaborate and work in partnership, so services worked seamlessly for people. Staff shared information and learning with partners and collaborated for improvement.

The service worked well with outside agencies. These included key relationships with the local authority, police, and mental health services. This was to provide care which was joined up and supported people to be safe and live well in their community. There were good relationships with the rest of the trust sites where services overlapped or were co-dependent. The service worked well with other local NHS trusts, community services, local schools, and local charities.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcomes, and quality of life for people.

The service used feedback from the children, young people and families to know when there needed to be changes and improvement.

Investigations were used to improve. For example, the report into learning from deaths clearly identified the trust’s ‘Listen, Learn and Share’ approach around learning and action.

There were education sessions for staff. For example, the service provided a paediatric medication rapid improvement programme to educate and support staff to improve patient safety around medication. This had been identified due to a high number of medicines incidents during 2023 and an internal audit. The programme ran between December 2023 and August 2024 and covered the results from 50 medication audits, incident report data, themes, and trends. Staff were reminded of the correct procedures for medicines management and preparation, reporting on incidents and looking for adverse effects in patients. Follow up feedback from staff after the programme was positive and the service saw improved completion of medication charts and the number of incidents staff reported rose due to a better awareness of the reporting policy.

The service introduced monthly practice update information sheets which were produced by the Quality and Clinical Assurance Team. These information sheets gave updated information on clinical practice with a different subject topic each month. For example, the January 2025 information sheet contained guidance on making a rapid assessment of a patient’s level of consciousness and an easy tool to for staff to use and steps to follow for escalation if they had concerns.

Parent feedback was sought through the trust-wide NHS Friends and Family Test survey. However, the service also recognised that this tool did not always hear the voice of the child and therefore they developed child specific feedback forms for inpatients, outpatients and the community. The forms were age and development specific and approved by service users. On the wards the play team promoted the voice of the child through ‘Pants and Tops.’ Children gave feedback, and their comments were written on ‘tops’ and ‘pants’ which were displayed on ‘washing lines’ on the ward.

The children’s team worked with local schools to develop areas highlighted as a theme and had recently adapted the food menu on the wards.

The neonates team worked with the Maternity and Neonatal Voice Partnership to review any proposed changes or produce services as a form of co-production. They actively worked with parents and carers with a ‘family integrated approach’ and had a support group for babies that graduated from the neonatal unit.

The service booked an ‘autism bus’ for staff training in 2025. This was an autism reality experience bus, an immersive training tool developed to help non-autistic individuals understand the sensory challenges faced by people with autism. The bus provided a simulated sensory experience, allowing participants to better understand the difficulties autistic individuals may encounter in everyday situations.