Birmingham Heartlands Hospital

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• Overview
• Kindness, compassion and dignity
• Treating people as individuals
• Independence, choice and control
• Responding to people’s immediate needs
• Workforce wellbeing and enablement

People were treated with kindness, empathy and compassion. Their privacy and dignity were respected as much as possible but because of the challenges of the environment they sometimes had a poor experience. People were able to make their own decisions and be understood. Staff were generally supported but suffered stress due to the high-pressure working environment.

At our last assessment we rated this key question good. At this assessment, the rating remained good. This meant people felt well-supported, cared for and were mostly treated with dignity and respect.

We have not awarded this service a score for Caring.

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

While the service treated people with kindness, empathy and compassion, it was not always able to respect their privacy and dignity. Staff treated colleagues from other organisations with kindness and respect.

The service mainly treated people with kindness, empathy and compassion but there were difficulties in maintaining their privacy. However, when we looked at surveys about the department and information supplied by people who had contacted CQC there were comments about the attitude of staff.

Senior staff told us there was still work to be done in promoting a behaviour framework for staff and addressing fundamentals of care including civility and kindness. Part of this was an initiative to put the “Heart Back In Heartlands” and create a “Heartlands Welcome” for all patients.

However, during our assessment visit we observed most interactions with patients were caring, and we saw many examples of staff acting in response to a patient’s particular circumstances with kindness. This was despite the difficult circumstances in which staff were sometimes working. Almost all patients and relatives we spoke to during our inspection visit was positive about the way staff had interacted with them.

We observed patients being treated with consideration of their privacy and dignity. However, this was sometimes difficult as patients were close together in some places such as the resuscitation and ambulance assessment areas and separated only by curtains. It was often difficult for staff to speak to people in complete privacy and conversations could often be overheard. Staff told us it was difficult to maintain confidentiality for patients who were being assessed at the entrance by the streaming or navigator nurse. However, when an issue was sensitive staff always made an effort to make the conversation private.

Patients held on ambulances had their personal care needs attended to either on the vehicle, or, if they could walk inside the department in a cubicle that was set aside for this purpose. This was a practical approach, but staff told us some patients found it embarrassing.

Interactions between departmental staff and the ambulance service were generally cordial, despite the difficult situation of them often not being able to handover patients in a timely way. The role of the Hospital Ambulance Liaison Officer was helpful in maintaining good communications between the providers.

We did not look at Treating people as individuals during this assessment. The score for this quality statement is based on the previous rating for Caring.

We did not look at Independence, choice and control during this assessment. The score for this quality statement is based on the previous rating for Caring.

The service listened to and understood people’s needs, views and wishes. Staff responded to people’s needs in the moment and acted to minimise any discomfort, concern or distress.

Throughout our assessment visit we observed staff listening to patients and responding to their needs and concerns in a positive manner, this despite often being very busy with other tasks.

However, we were told by staff, and saw patient comments, that vulnerable people, including those with dementia, learning disabilities and autism often found the crowded and noisy environment distressing. While staff tried to offer quiet spaces, these were not always suitable nor available.

The children’s area of the department was suitably decorated and there were age-appropriate toys and amusements for distraction. There was previously a separate waiting room for adolescents, but this had been decommissioned and was awaiting conversion to a clinical area. This reflected the capacity demands and space constraints on the department and how it affected patient care.

There was a new quiet room to use when speaking to families and we were told this had been funded by staff raising money.

Despite the need for patients to be accommodated in areas of the department that had sometimes been repurposed, much thought had been given to how nurses were deployed. This meant that despite the challenges there was usually oversight of patients by staff and we saw that staff usually responded quickly to requests for drinks or to use the toilet. However, there was not always free staff and in 1 instance we saw a nurse who needed help supporting a patient had to escalate to a manager to release someone from clinical tasks to help.

The hospital was meeting the needs of the community in relation to seeking less urgent care. The local population had a particularly low rate of registration with general practice and those who were registered often preferred to seek their healthcare from the emergency department at Heartlands. Together with high levels of deprivation and chronic ill health this resulted in high numbers of patients attending the department with primary care needs. This was addressed through the assessment of patients at the front door and signposting them to suitable services while ensuring those in need of immediate acute care were assessed and treated.

Staff had access to an end of life and bereavement team who could be called to attend the department. They provided a full day’s training to the emergency department staff in end-of-life care and supporting bereaved families. Where a patient had died without relatives present, when they arrived, they were accompanied to the mortuary by nursing staff. There had been some incidents where the deceased had not been treated correctly, and these were, with the permission of relatives, referred to in the training courses.

There was a comfortable bereavement room for use by relatives and there were useful items such as bags for belongings and culturally appropriate adaptations such as modified shrouds. There were information booklets available, and these were comprehensive and reflective of the needs of local communities.

The service cared about and promoted the wellbeing of their staff and supported and enabled staff to deliver person-centred care. However, the high workload and frequent crowding in the department meant that staff were often under pressure, and some were unhappy and even unwell because of this.

The department was always busy and under pressure. During our assessment visit the demand was less than was usual and there was flow into the rest of the hospital. Nevertheless, staff were very busy and, in some cases, clearly under stress. All staff told us that they were under pressure at work, and some described ‘moral injury’ when they could not care for people in the way they wanted to. Some also said they worried about making mistakes and their professional registration.

When we spoke in more detail to staff who reported negative experiences this was because of the stresses of working in an environment where they could not always provide the care they wanted to. One person said, “some days are calm, some days are terrible.” We spoke to a small number of staff who said they were stressed and thinking of leaving to work elsewhere. One person told us they recently “left work and cried” the previous week because of severe crowding overnight in the ambulatory area and the risks that presented. They said that because it was at night “no-one senior came to look.”

However, many staff who had worked in the department for years were positive about the new leadership team and recent changes. Several said communication was better, and staff were listened to and another said there were now “hard conversations” as staff were being supported and managed to perform. Another person told us the department was now “so different,” that “people want to come to work” and it was “such a good place to work.” One member of staff told us they had returned because they had been told things were better and another said that they had come to work in the department on the recommendation of a friend.

Staff in the children’s area told us they felt comfortable at work, and 1 said there was a “happy and kind culture.”

Some staff and patients reported concerns about their physical safety in the department and feeling uncomfortable around some patients. While such issues were often a concern in emergency departments staff said it was made worse as people because frustrated because of overcrowding and waiting. Staff had emergency call buttons that could be used to summon security staff, and they told us the police were responsive when called. Training was being developed to allow staff to physically restrain people if necessary.

Staff in children’s area told us they had few concerns about security and that on the few occasions they were needed, security personnel were responsive.

A newsletter had been introduced and as well as managerial and clinical information there were articles about wellbeing and positive stories about the department and its staff.

Two members of staff told us they were observing Ramadan during our inspection and that “work has been flexible” to allow them and their colleagues to meet and break their fast when on nightshifts.