Solihull 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

There was a positive learning culture with staff managing incidents well. Learning from incidents was evident. Staff knew what incidents required reporting and how to report them. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. There were processes in place to ensure the service had enough staff with the right training, skills and qualifications to keep patients safe from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We were unable to gather enough evidence for this as patients remained in the department for short periods of time but there were no concerns reported.

All staff knew what incidents to report and how to report them via the online reporting system. Staff raised concerns and were encouraged to report incidents by their managers. Staff told us that changes had been made because of feedback. For example, there had been an incident of conflict between the minor injury team and the minor illness team about who should see a patient who had arrived with an illness but did not have a booked appointment. The teams had a meeting, and a new policy was written to make it clearer for staff regarding the patient pathway. The manager stated they were concerned as not all staff had completed minor illness training so it would be a risk for these patients to have been seen by the minor injury team. The service had no never events or serious incidents since they had opened in June 2023. Staff had reported 70 incidents including 6 near misses; there was a positive culture for incident reporting and learning. Managers investigated all incidents and complaints thoroughly and implemented changes where needed. Staff understood the policy on complaints and how to handle them. Managers shared feedback from complaints with staff and learning was used to improve the service. Staff could give examples of how they used patient feedback to improve daily practice. We saw an example of a complaint relating to safeguarding and the team learned from the incident and shared the learning with the team.

The trust had clear policies for incident management. They explained how to report, categorise, and investigate incidents. Incidents were discussed within governance meetings. Where learning was required, there were processes to follow for staff to ensure this was shared and embedded. Managers used several methods to share learning with staff including an encrypted social media group and team meetings. Staff gave examples of changes implemented following incidents to improve patient care. No serious incidents had occurred in the unit, but most staff were aware of the duty of candour and how to use it if required.

There was a monthly teaching session for EPs on X-ray interpretation and missed fractures. We were told they did not get many missed fractures but wanted to ensure competence for assessing x-rays was high.

Staff mostly worked with people and partners to establish and maintain safe systems of care. However, some patients who attended the department were advised to attend an emergency department by the reception team without an assessment by the nurse or EP. We fed this back to the managers who reviewed and discussed their standard operating procedure with leaders of the service and held meetings with staff to ensure they were following the correct assessment process. Staff mostly ensured safety was monitored, managed, and assured in line with national guidelines. However, not all patients were seen promptly. All patients were assessed by a nurse, but this was not always within 15 minutes of arrival into the department. The average time to be seen was 27 to 30 minutes. Initial assessments did not always occur as they were short-staffed for assessment nurses. Reception staff were responsible for ensuring the patients were seen in the correct department. If patients were streamed to the wrong area by the reception team, they were transferred to the partner team in minor illnesses with a handover of any information that had been obtained. This was not always an easy process as this minor illness service was an appointment only service and appointments were not always available immediately.

We spoke to the staff within the minor illness team who told us patients moved seamlessly between the two areas where required. They had joint meetings with the ICB and managers of the MIU where information and learning were shared, and they ensured information was aligned.

There was a standard operating procedure for the MIU which detailed how care would be transferred or escalated where required. There was an emergency and critical illness pathway which all staff were aware of and followed to ensure safe transfer of care. All patients who were transferred between services were handed over verbally to a consultant within a neighbouring hospital or sent with a summary of their condition if they were not transferred within the trust.

The service was predominantly a walk-in service, but patients were also referred into the service via ‘111’. There were 3 available appointments an hour for this. We were told these appointments were underutilised. However, when booked, they were not always appropriate referrals. For example, on the day of the assessment a child who was short of breath was referred and an adult with diarrhoea. Staff told us they had not fed this back to the service. Inappropriate referrals were discussed in the March 2024 team meeting and actions were identified to try and reduce these. Patients did not always attend the department for the appropriate reason. They had had an increase in patients attending for routine wound dressing changes which was not in their scope of practice. We saw this was an action within their directorate meeting to discuss with the ICB to find a solution. The service had a meeting with the ICB and the minor illness managers. We reviewed meeting minutes from April and June 2024 which showed discussions around joint pathways and developing them together. These included a ‘red flag’ pathway and a ‘2222’ pathway. We saw there were clear actions in the action plan for completing these together.

We were unable to gather enough evidence for this but there were no concerns reported.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff knew how to make a safeguarding referral and who to inform if they had concerns. All staff we spoke to had a good understanding of the safeguarding policy. Staff received training specific for their role on how to recognise and report abuse. Training levels were 100% for clinical staff for Safeguarding Adults and Children Level 3 and Safeguarding Level 1 for non-clinical staff. Staff could give examples of how to protect patients at risk of, or suffering, significant harm.

The service saw patients over the age of 12 months with a minor injury. Their assessment included ensuring recognition and response to any safeguarding children issues raised. We looked at 4 sets of paediatric notes and the safeguarding checklist was completed for all of them. There was a small waiting area where children were able to play; it was not fully separated from the remaining waiting area. Staff told us they would move children into cubicles if they needed to safeguard them. Staff understood the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) and had completed training on these. Staff told us they occasionally had patients who had suffered from mental health conditions and had a room where they could wait. Staff got advice from their mental health colleagues as required.

The trust had a clear safeguarding policy and pathway which was up-to-date and accessible to staff through the trust’s intranet. Staff had access to the trust’s safeguarding lead for advice. There was a standard operating procedure which detailed how to safeguard children within the department. All staff we spoke to were aware of this and all safeguarding procedures.

Staff asked all children and families if they were known to social services, had an allocated social worker or were on a child protection plan. Reception staff performed a child protection information system check and recorded the outcome of this on the patient front sheet; we saw this was recorded on all 4 paediatric notes we checked.

We spoke to 5 patients who all felt safe in the department. They felt supported to understand and manage any risks. They were given information about what to do if their injury got worse.

Each patient had an initial assessment by the nurse. National standards recommend patients are assessed within the first 15 minutes of arrival. The average for assessment time at the MIU was 27 to 30 minutes. Staff allocated a risk score to the patient following the assessment. Most patients were allocated a risk score of green which meant they could be seen within 4 hours. If they were allocated, yellow, orange, or red, they were seen immediately by the EP as this meant they needed a prompt senior review. Staff mostly identified and quickly acted upon patients at risk of deterioration. Nurse triage consisted of an assessment of their injury and medical history, asking them about their pain and offering pain relief if required. The assessment nurse did not ask for a pain score in the assessments we observed. We were told all patients’ pain should be assessed within triage. We saw this was always asked within the assessment completed by the EP. We observed an assessment of a patient who had a fainted prior to attending, and the nurse did not take their observations. We reviewed 9 records and found patients’ pain was acted upon by staff and patients were reviewed promptly when needed. Patients who attended the department mostly had minor injuries but occasionally patients attended who were acutely unwell. Staff told us they could get advice from a consultant at Birmingham Heartlands Hospital who was assigned to provide advice and support to their service. Staff completed mandatory training; data showed 97% compliance.

We spoke to an advanced nurse practitioner within the minor illness department. They felt the EP’s were very supportive and they worked well together to keep the patients safe. They told us if they had an unwell patient, the EP’s would support them alongside the emergency medical team where required. They told us the EP’s were very knowledgeable and they could approach them for advice regarding patient care.

There was a standard operating procedure (SOP) which detailed what pathways staff should follow for patients who attended the department. We saw reception staff seeking advice from EP’s about patients who had attended the service and turning patients away who were not appropriate; this was not in line with their SOP. This SOP required patients to be seen by a nurse or EP to undertake an initial clinical assessment or redirect the patient to the correct pathway. We raised this with the managers who reviewed the SOP and discussed it with the leads for the service and communicated the process clearly to all staff. The SOP also detailed what staff should do if a patient became unwell. There was resuscitation equipment available, and assistance could be sought by calling ‘2222’ and the hospital emergency team would attend. There were clinical pathways for managing paediatric and adult emergencies. This included arranging an ambulance transfer to another hospital within the trust for further treatment. There were several clinical pathways for staff to follow in the department. These were in line with emergency departments. For example, there was a pathway for head injuries, lower limb immobilisation following a venous thromboembolism and an acute knee injury pathway. There was a huddle at the beginning of each shift where staff followed up on any tasks that were outstanding for patients from the previous day including informing patients of their blood results and the implications of these. Staff completed clinical life support (level 2) training; 72% of EP’s and 100% of assessment nurses and HCA’s had completed this. Managers told us there were regular reminders emailed to staff who needed to complete this training.

People we spoke to felt the environment was good. There was enough space in the waiting room when people were waiting and there was a small area for children to play in whilst they were waiting to be seen. This area had a projector screen onto the floor which children enjoyed.

All staff told us they had access to suitable equipment to enable them to complete their role. Equipment was well maintained and regularly serviced to ensure patients were kept safe. The service had suitable facilities to meet the needs of patients. Staff were happy with the environment. There was an eye examination room that they felt was a great addition to the space and meant they could assess patients’ eye injuries effectively due to the blackout blinds in the room. Staff told us they were raising money to turn cubicle 1 into a paediatric cubicle and make it a more suitable environment for children.

The design of the environment followed national guidance. The area was purpose built to assess patients. There were 7 cubicles which all had adequate space to assess patients, 4 assessment rooms, a plaster room, and an eye examination room. Equipment was observed to have been serviced, electrically tested, and had details of when next checks were due. They had a ‘wobble’ room where patients could go if they needed a private space. It was used for patients who had neurosensitivity, learning disabilities or patients and staff who needed a quiet space.

There was a resuscitation policy which required staff to check the emergency equipment daily. We saw staff carried out daily checks of specialist equipment. There was a monthly environmental audit. Results were consistently 99% and above in 2024. Auditors made recommendations to increase compliance such as “recommend repair of wall panel”.

Patients felt there were enough staff. There were no concerns reported.

The service mostly had enough nursing staff with the right qualifications, skills, training, and experience to provide the right care and treatment. There was a 0.5 whole time equivalent vacancy for assessment nurses. The actual rate of assessment nurse vacancies was higher but there was a trainee Band 6 EP who had suspended their training and was working as an assessment nurse. However, we were told some shifts were not covered and EP’s either completed an initial assessment or they just reviewed patients when they were able. There was a low vacancy rate of 4% for the EP’s across the service and a turnover of 0%. Managers calculated and reviewed EP, nurse, and HCAs needed for each shift in accordance with national guidance. There were always at least 2 EP’s in the department. Additional EPs were on duty throughout the day with peak coverage between 11am and 8pm. All EP’s rotated across the different sites within the trust for education, training, and development. There was a high vacancy rate for HCAs of 61%. They had a bank HCA who had been on a block booking for the past 6 months and wanted a permanent position. We were told the job had been advertised shortly after our assessment.

The service had increasing sickness levels for qualified staff; they had increased from 4.1% in January 2024, which was in line with the trust target of 4%, to 11.15% in June 2024. Staff absences were mostly covered with existing staff, staff from other emergency departments or bank staff. Between 36% and 44% of shifts for qualified staff were filled by bank staff between January and June 2024. The service used bank staff and requested staff familiar with their service. Managers made sure all bank staff had a full induction. All EP’s had or were undertaking a university accredited minor injury and illness training course which included paediatric competence. We saw 100% of EP’s had completed minor injury training which included paediatric competencies.

During our onsite assessment, we found the number of EP’s and HCA’s matched the planned numbers. There was a bank assessment nurse, but they were struggling to complete assessments in line with expectations, with no initial assessments occurring within the 15 minutes national standard. We were told this often happened as there were patients queuing to be seen when the department opened at 8am. We observed the EP’s assisting the assessment nurse when needed.

There were processes in place for bank staff to undergo a local induction. This ensured information about the unit’s specific needs and policies were discussed. The lead EP had a meeting on a Monday to discuss staffing with their EP managers for each site. Staff were moved where required to ensure safe staffing levels were met across the organisation. Managers told us that as Solihull was a nurse-led unit, it was always covered with EP’s as other sites were able to fill the shifts with medical staff. Managers said they were currently reviewing staffing levels and whether they needed to be increased in line with patient demand. Staff were experienced, qualified, and had the right skills and knowledge to meet the needs of patients. Managers made sure staff received specialist training for their role. EP’s received university accredited training which involved minor injury, minor illness, and medical prescriber training. 100% of staff had completed minor injury training and 38.2% had completed the full course including illness and non-medical prescriber’s course. All others were working towards being fully compliant with these; it took 4 years to complete the full training. Managers supported staff to develop through yearly, constructive appraisals of their work. Data showed 87% of EP’s had an appraisal and 80% of assessment nurses and HCA’s had a completed appraisal within the last 12 months. All staff who had not had their appraisals had these booked to be completed. There was a lead educator who supported the learning and development needs of staff. They did 1-to-1 teaching and supported staff who were on the EP course to complete their competencies. We found there were good opportunities for staff to develop and learn in the department.

Patients told us the environment was clean and tidy. They told us staff washed their hands before and after contact.

The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves, and others from infection. They kept equipment and the premises visibly clean. Data provided showed 97% of staff were trained in infection prevention level 1. Cleaning records were up-to-date and demonstrated all areas were cleaned regularly.

During our onsite assessment, we found the unit was clean and had suitable furnishings which were clean and well-maintained. We observed staff cleaning equipment after patient contact, and we saw ‘I am clean’ stickers dated for 2 July 2024. We observed staff performing hand hygiene before and after contact with patients.

There was an infection prevention and control policy in place for staff to follow.

The service generally performed well for cleanliness. The unit had not had a formal infection prevention and control (IPC) audit completed since it had opened in June 2023. The IPC nurse had arranged training for the matrons so IPC assurance audits could take place. We saw hand hygiene audits were undertaken. Compliance between April to June 2024 ranged between 87.95% and 91.04%. The area of cleaning hands after touching a patient environment scored the lowest in each audit. However, there was no action plan to improve compliance. Managers told us results were displays on notice boards, so staff were aware of where practices needed to be improved. There was a housekeeper between 9am and 10pm who helped to maintain a clean environment.

We did not gather enough evidence to rate this, but no concerns were raised.

Staff told us that they knew how to contact pharmacy for advice and processes were in place for the supply of medicines. Staff told and showed us how they had access to relevant medicine policies, procedures, and guidelines. Staff had access to a medicines online learning programme. Staff said that there was a good relationship with the pharmacy team which was helped by a pharmacy link nurse in the department. Pharmacy was available to support them with managing medicine processes such as feedback from audits on medicine management, ordering and receiving medicines. However, staff also told us that a pharmacy assistant was hopefully going to be appointed to work in the UTC to provide further medicines support.

We observed that medicines were locked and secure. However, we also saw medicines were not always stored safely in line with recommended practice. Whilst, medicine storage and security checks were undertaken and recorded regularly, we found some medicines requiring refrigeration had gone past their expiry date. This increased the potential risk of a medicine being given that may not be effective. These were removed and destroyed immediately. Controlled drugs (CDs) were stored safely and securely with access restricted to authorised staff. Checks were undertaken and recorded by 2 staff daily. Checks of CDs showed that they were within date and stock balances were accurate. Resuscitation medicines required in an emergency were stored safely in tamper-evident boxes which followed Resuscitation Council (UK) guidance. We observed that staff recorded safety checks to ensure the medicines were safe to use. Medicines for refrigeration were stored securely with records available of maximum and minimum temperatures to ensure the medicines were stored safely. Staff knew how to escalate any temperature breaches and what action to take to ensure safe medicine storage. We observed the destruction and removal of waste medicines from the unit.

Processes were in place to ensure people received their medicines. Medicine administration records were well documented. The pharmacy department conducted medicines management and medicines optimisation audits including controlled drugs. Results had improved from 77% in September 2023 to 84% in June 2024. We did not see an action plan associated with the audit. There was a safe and secure handling of medicines audit which was completed every 6 months. Compliance was above the trust target of 85%. There were no associated action plans, but we were told results were shared with staff via group messages. We did not see these results shared in staff meetings from the minutes we reviewed. We reviewed multiple people’s medicines administration records. They were well documented with route and time of administration. The information showed people were receiving their medicines as prescribed. Allergy status of patients was routinely recorded on all medicine records seen. Processes were in place to record pain assessments and that appropriate pain relief was prescribed, administered, and recorded. There was a clear process in place for managing and reporting any incidents involving medicines. Staff were able to talk through the process that would be followed if this occurred. There was a good safety culture that encouraged staff to report these. An example was given where action was taken from an incident which was shared across the team.

There was a process to ensure that Patient Group Directions (PGD) were current, but they were not all up to date due to the high amount of PGDs that required review and approval. Pharmacy had highlighted the issue, which was on the risk register. The managers had to always ensure there was a nurse prescriber on site whilst there PGDs were in development. There was no PGD specific pharmacist allocated to provide support for PGD development. The PGD’s were discussed in the directorate meeting and the need to review and progress them further.