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 rated well-led as good. Leaders understood and embodied the culture and values of the workforce and the organisation. They had the skills and knowledge, experience and credibility to lead well. They demonstrated their integrity and honesty which was recognised by their staff. There was a clear system of governance and risk management based around delivering safe and good quality care and treatment.

At our last assessment we rated this key question requires improvement. At this assessment, the rating has improved to good. This meant the service was consistently managed and well-led.

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.

The trust had a strategy for 2024 to 2029 of ‘Building Healthier Lives’ with 5 key priorities but when we spoke to leaders within the emergency department this was not mentioned. It was occasionally referenced in documents we were sent following our data request but was not a focus for the department and we did not hear mention as to whether or how it was being developed. Current development was piecemeal and reactive.

Long and medium-term direction was focused on the ambition to replace the existing emergency department with new facilities. These would address the issue that demand on the department far exceeded capacity and that the configuration of the existing department did not lend itself to modern care models.

The hospital had a clear long-term vision to have a new emergency department and in the medium term an urgent treatment centre. This was well articulated in documents we saw and frequently mentioned in the conversations we had with senior managers and leaders. However, delivering this was dependent on substantial capital investment which the trust was trying to achieve through national public dividend capital.

Without this funding the department would continue to rely on piecemeal improvement which while mitigating some immediate problems did not address the fundamental issues of the size, age and configuration of the department.

There was a consistent vision from the service’s leadership. When speaking to staff who were in supervisory or management roles, they gave a consistent description of what the department wanted to achieve. This included both in long-term ambition to expand the department and in the shorter term to make improvements within the current constraints. This had been communicated to staff through briefings and newsletters. One band 5 nurse articulated this, saying “the new senior team all have the same vision.”

There was an improved and improving culture in the department. Staff frequently spoke of “then” and “now” and among many there was a sense of an improvement journey. Staff generally looked after one another and spoke positively of their colleagues, both in their own and other professions or roles.

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 leadership structure in the department for nursing, medical and other staff. They were all experienced leaders and there was a healthy mix of people promoted from within the department with people who had come from other organisations.

Senior staff told us they had made efforts to be more visible and approachable in the department by being present and holding drop-in staff clinics when they would be in an identified office during a specified time. Most staff said senior staff were often present in the department, but a few said they did not often see them. One manager commented that because of the layout of the department it was possible to be there all day and for someone to truthfully say they had never seen them.

Many staff who had worked in the department for years were positive about the new leadership team. Many said communication was better, and staff were listened to. One 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.” A third said that “the new band 7s” were present and supportive and that the matron “could see what needs to be done.” Someone who had left and come back to the department told us that “management are now amazing.” They cited colleagues having told them this as the reason for them returning having previously left because of dissatisfaction.

However, other staff reported that at night there was less support. One said that after a very pressured night said they went home and cried and that was, because it was at night, “no-one senior came to look.”

Staff in the children’s department reported there was a positive culture, the atmosphere was described by one member of staff as “happy and kind.” and there was a “flat hierarchy with 360-degree feedback.”

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

There was a culture of openness and honesty, and junior staff openly described their concerns to us in front of senior staff. Similarly, leaders and managers were candid about their challenges and, while talking positively about plans and solutions, talked to us about and showed us the problems they were encountering.

The NHS Staff Survey for 2024 flagged the ability to raise concerns as red, or worse than other trusts. However, staff we spoke to reported that the leadership team was now far more open and told us they were not afraid to speak up. When people did say they would be reticent to do so, it was in the context of incident reporting when they believed nothing could or would be done about the issue. We also saw initiatives to enable staff to speak up including leaders holding open door clinics at set times each week.

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.

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

Our previous inspection had identified that there were not always effective governance and management arrangements. On this assessment visit we saw there had been improvements, and that management and governance processes were largely effective.

Leaders and managers had sufficient time to carry out their governance and managerial responsibilities. Those in a clinical role were able to balance their clinical work with their leadership duties.

When we raised issues with senior staff, they were almost always aware of them and could explain the root causes, what mitigation was being used, and what long-term solutions might be implemented. However, these solutions were often reliant of significant funding and recruitment of staff, neither of which were immediately available.

The trust was implementing a new risk management system and was in the process of transferring information from the old to the new. There was an expectation that the emergency department would meet regularly with their Governance Facilitation Lead to discuss risks.

We requested and reviewed the risk register for the emergency department. It correlated well with the risks we had seen and been told of during our inspection visit as did the plan to reduce and mitigate the risks. The top risks were also visible to all staff through the departmental newsletter which described the problems and approaches to dealing with them.

Clinical governance meetings for the emergency department took place regularly and as they combined their oversight with the Good Hope Hospital’s department the 2 sites were linked by video for the meetings. There was separate consideration of site-specific issues as well as common themes. At the meetings, staff discussed trends in patient safety incidents and those of significant concern were discussed in more detail for learning. Top items on the risk register were discussed at each clinical governance meeting and actions noted and, if necessary, chased up.

Clinical governance meetings also discussed complaints both in terms of trends and when needed, individual incidents. Royal College of Emergency Medicine audits were presented and discussed.

The governance meeting minutes were distributed through email and on notice boards to be available to all staff. Team meetings for band 7 nursing staff took place but were not minuted, which having been done would have demonstrated any actions taken or required. Safety huddle meetings that took place throughout the day were noted and combined into a single document both as a record and to inform staff at changeover through email and on noticeboards.

Mortality and morbidity meetings took place, and we saw evidence of good attendance from consultant, specialist and some resident medical staff. The notes of the meetings demonstrated that human factors, training and the adequacy of existing guidelines were considered. We saw evidence of learning from these meetings such as improved clinical guidelines for bleeding disorders.

The matron produced a monthly quality assurance report. This report had the stated purpose of monitoring and addressing the quality of patient care. It was to ensure compliance with statutory requirements and making sure learning was acted on and shared. The reports were candid and comprehensive, and the issues discussed demonstrated a good understanding of the challenges faced by the department and correlated well with the inspection team’s findings. Shortfalls in quality were noted and proposed mitigation and actions explained. Where actions had addressed previous problems, these were noted and celebrated, but it was also recognised when approaches had not been successful.

The department was one of the first 5 departments in the country to receive the Royal College of Emergency Medicine’s environmental sustainability accreditation, receiving the bronze award in the autumn of 2024.

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

Many of the processes, audits and governance arrangements were part of hospital, trust, or health economy-wide mechanisms and the department worked with other departments, providers and agencies.

A hospital ambulance liaison officer provided by the ambulance service, but funded by the trust, was at the department 24 hours a day. This worked well, was valued by both organisations and they played a key role in supporting the newly introduced rapid ambulance assessment process.

The department and the trust as a whole worked with mental health providers, the integrated care board, general practitioners and other providers and agencies. That some of the problems were proving intractable was not a reflection of their collaborative approach.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for people. Staff actively contributed to safe, effective practice and research.

There was clear evidence in the department of innovation and improvement. The requirement for improvement was frequently prompted by the challenges the department faced from demand and difficulties in transferring patients out of the department. Innovation was often driven by addressing these issues within the constraints of the estate, the environment and staffing.

The department fed learning from audits, incidents and complaints into its management and clinical governance structures and these generated discussions about root causes and possible solutions and mitigations. These solutions were sometimes novel but were implemented with their benefits assessed against any risks that might be introduced.

Several staff in the children’s department said they needed a paediatric clinical educator. We understood that, as in the adult area, there was a business case under consideration to create this role to work across the Heartlands and Good Hope sites.

Since our last inspection there was now a framework for education and training. Leaders told us they were starting a ‘back to basics’ initiative including a ‘fundamentals of care’ day. An example we were given was that nutrition and hydration in the department was previously a dedicated task for a healthcare assistant, but it was now part of everyone’s role.