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We are carrying out a review of quality at City Hospital. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 5 April 2019

Inspection areas

Safe

Requires improvement

Updated 5 April 2019

Effective

Good

Updated 5 April 2019

Caring

Requires improvement

Updated 5 April 2019

Responsive

Requires improvement

Updated 5 April 2019

Well-led

Requires improvement

Updated 5 April 2019

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 5 April 2019

Our rating of this service stayed the same. We rated it as requires improvement because:

  • The provider failed to have robust governance systems in place to mitigate and protect patients from all the risks identified at our last inspection.
  • The provider had not ensured that patients would be consistently supported by the number of staff needed to meet their specific needs.
  • Processes in place did not always protect patients from the risk of infection.
  • Processes in place had not ensured emergency equipment and fittings would be available consistently when patients required resuscitation or support after a fall.
  • Patients were at risk of receiving inappropriate or unsafe treatment because records were not always fully completed by staff.
  • Staff did not always manage patient information to minimise the risk of confidential information from being accessed by other people.
  • Staff largely understood the Mental Capacity Act 2015 but did not always take action to assess if patients had the mental capacity to consent and choose how they wanted to be supported.
  • The provider had not met its mandatory staff training and appraisal targets which put patients at risk of being supported by staff who did not have the skills and knowledge to meet their basic care needs.
  • Patients were at risk of experiencing delays in receiving suitable care because staff could not always access scans and test results promptly due to unreliable electronic records and IT systems.
  • Some staff were unclear if they could use agency staff which put patients at risk of not being supported by sufficient staff to meet their needs.
  • Leaders lacked the skills to effectively addressing ongoing concerns about the service.

However:

  • The risk of patients experiencing avoidable harm was reduced by staff who knew how to report incidences and received guidance on how to prevent similar incidences from happening again.
  • Upgraded storage systems and discharge processes gave patients quicker access to medicines.
  • Increased clinical ward cover meant that patients had quicker access to suitable clinicians and up to date care plans.
  • Board/ward rounds had been reviewed to reduce the risk of patients experiencing delayed discharges.
  • Patients said they enjoyed their meals and staff knew how to meet their specific nutritional needs.
  • Staff told us they enjoyed supporting patients and were knowledgeable about the service’s vision and values.
  • Staff said senior staff were prominent around the hospital and welcomed their suggestions about how patient care could be improved.
  • Patients were protected by staff who knew what action to take if they though people were at risk of or experiencing abuse.
  • Staff respect the legal rights of patients by supporting them in accordance with their DoLS authorisations.
  • Staff understood their duty of candour so patients would receive full and detailed explanations if things went wrong.
  • Patients were supported to make informed decisions about their life style choices because they had access to advice and guidance about their specific conditions and how to manage them.
  • Good outcomes for patients were supported by the use of evidence based practice.

Services for children & young people

Requires improvement

Updated 5 April 2019

Our rating of this service stayed the same. We rated it as requires improvement because:

We rated safe and responsive as requires improvement, effective and caring as good and well-led as inadequate.

  • Staffing levels were not sufficient. The service did not have enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment
  • The service inconsistently managed infection control and the environment was not always suitable to provide the safe care and treatment of children.
  • There was a lack of consistency in how the mental capacity of children and young people was assessed and not all decision-making was informed or in line with guidance and legislation.
  • The trust did not provide Mental Health Act 1983 (MHA) training to its staff as a separate module.
  • The service had not engaged or involved children and young people and their families in the design or delivery of the service.
  • Leaders did not always have the experience or knowledge that they needed to carry out their roles.
  • The trust did not have a strategy for children and young people services relating to paediatrics or neonates.
  • There were low levels of staff satisfaction and high levels of stress and work overload.
  • The arrangements for governance and performance management were not fully clear. clear.
  • There was inconsistent understanding or management of risks and issues.
  • Staff were unaware of what information was used in reporting or performance management.

However,

  • The service provided mandatory training in key skills to all staff. There was a structured induction programme which staff spoke highly of.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • The service provided care and treatment based on national guidance and maintained (?) evidence of its effectiveness.
  • The service monitored the effectiveness of care and treatment and used the findings to improve them.
  • Staff responded compassionately when children and young people needed help and they supported them to meet their basic personal needs as and when required.

Critical care

Good

Updated 26 March 2015

There were effective processes in place to learn from incidents. There were sufficient numbers of nursing and medical staff on duty. Medicines, including controlled drugs, were safely and securely stored.

We found there was good multidisciplinary team working across the unit.

There was strong medical and nursing leadership within the critical care unit. Staff felt well supported within an open, positive culture.

End of life care

Outstanding

Updated 31 October 2017

We rated End of Life Care as outstanding because:

  • The palliative and end of life care service was tailored to meet the needs of end of life patients. Advice was managed and timely to take into account patient’s individual needs, including for patients with urgent needs.

  • The palliative and end of life care service worked together with commissioners and other providers to plan new ways of meeting people’s needs. The service had a strong focus on innovative approaches of providing integrated care pathways, particularly for patients with complex or multiple needs.

  • Patient admission, discharge and moving patients between hospital care and care in the community followed models of best practice in integrated, person-centred care.

  • The palliative and end of life care service designed services to meet the needs of the local community to enable all people to access palliative and end of life care services.

  • Patients had seamless access to palliative and end of life care, support and advice 24 hours a day, seven days a week.

  • Experienced staff provided a compassionate and responsive evidence based service for end of life care patients.

  • Incidents for the palliative and end of life care service were low. Staff were knowledgeable about the trust’s incident reporting process. We saw concerns were investigated thoroughly and learning widely shared.

  • The service had one single point of access for patients and health professionals to coordinate end of life care services for patients.

  • The palliative and end of life care service was well developed across the trust and held in high regard by all of the wards we visited.

  • End of life and palliative care was a priority for the trust. The service was well developed, staffed and managed as part of the iCares directorate within the Community & Therapies clinical group.

  • There was a clear governance structure from ward and department level up to board level.

  • Good governance was a high priority for the service and was monitored at regular governance meetings.

  • Staff were proud of their service, and spoke highly about their roles and responsibilities, to provide high levels of care to end of life patients.

  • We saw this often exceeded patient’s medical needs. We were told of numerous examples where the staff had gone the extra mile. This included arranging a wedding for a person in their last few days of their life to marry their long term partner. Staff had decorated the ward to make the event as special as possible.

  • Advanced care plans and specialised care plans were used across the trust for end of life patients. They were used as a person centred individual care record to include all the needs and wishes of a patient and their family.

  • The trust used a Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) form. The trust DNACPR was easily identifiable with a red border and was stored at the front of the patient notes. We saw all DNACPR forms were completed accurately on the wards. This was much improved from concerns raised during our last CQC inspection in October 2014.

However;

  • We saw mortuary staff were not following the trust’s infection control policy. We were not assured the service was protecting mortuary staff and the general public that visited the mortuary from potential health and infection risks.

  • Mandatory training for mortuary staff did not include infection control training.

Outpatients and diagnostic imaging

Good

Updated 31 October 2017

We rated this service as good because:

  • We saw that staff reported the majority incidents of all levels and staff we spoke with were clear of the policies and procedures around this.
  • We saw that all areas were visibly clean and tidy and that there were processes in place to ensure these standards were maintained.
  • We saw that equipment was risk assessed and tested to ensure all risks were minimised
  • We saw examples of positive multi-disciplinary working and staff told us this was consistently good across the trust.
  • Policies and guidelines used were up to date, relevant and staff had access to them.
  • In the imaging department, local Diagnostic Reference Levels (DRLs) had been established, were reviewed regularly and reduced by the medical physics service whenever possible. We saw evidence that DRLs were discussed in IRMER committee meetings and we saw that mostly these were better than the national average.
  • We saw staff fully explain the process for assessment, examination and diagnosis and treatment in a clear way for the patient to understand. Patients we spoke with told us they had felt fully involved throughout their consultations and treatment.
  • We saw examples of innovation that would improve patient experience.
  • Extra clinics took place throughout the day and during the evenings to meet the demand of services and to reduce waiting times for patients.
  • The BMEC waiting area and processes for appointments had certain adaptions in place to meet the needs of patients using this specialist building. This included colour coded waiting areas, one-stop clinics, induction loops for the hearing impaired and a designated car park.
  • Staff told us that their local managers were supportive and worked with them towards improving care for patients. All of the staff we spoke with told us they felt they could raise issues with senior staff if they needed to.

However:

  • From April 2016 to March 2017, one ‘never event’ had been recorded at BMEC.
  • We saw that some rooms containing sharps bins were left unlocked and were therefore accessible for the public. We also saw some items that should have been stored under the Control of Substances Hazardous to Health (COSHH) were in unlocked cupboards.
  • Resuscitation trolleys were left open in patient areas and did not have tamperproof tags.
  • Staff told us about frequent incidents involving the escalator in the Birmingham Treatment Centre. The data provided did not reflect the amount of incidents that the staff told us occurred, therefore we had concerns that not all incidents were reported with regards to the escalator.
  • We saw that patient records were at times left on trolleys or desks unattended. This meant that staff were not always protecting patient confidentiality.
  • Staff in the outpatients department did not have their competencies regularly assessed to ensure they were confident and competent to carry out their role.
  • The layout of the consulting rooms in the BMEC orthoptics department did not always ensure patient’s privacy and dignity were protected.
  • There were no chaperone notices in any of the outpatient areas.
  • Staff told us that clinics often went over the scheduled time and patients could therefore be waiting longer than expected.
  • There had been a workforce review of staffing for the service across all OPD services, which had led to significant changes in the two years prior to the inspection. Staff told us they had not felt part of this and that they felt unaware of the strategy for the future of the service.

Surgery

Good

Updated 31 October 2017

We rated surgery services as Good because:

  • The trust held 10 quality improvement half days (QIHD) per year during which time staff shared learning and attended relevant training.

  • Robust application of the World Health Organisation’s (WHO) ‘five steps to safer surgery’ checklist was visually monitored on a daily basis.

  • Staff were aware of Duty of Candour and their role when things went wrong; they had an understanding of the Mental Capacity Act 2005.

  • Staff were seen adhering to the infection control policy of arms bare below the elbow. The use of hand sanitiser and protective clothing policy was also adhered to.

  • Theatres and the wards were clean and tidy; cleaning schedules were dated, signed and displayed.

  • Medication refrigerators temperatures were recorded daily and medication cupboards were locked.

  • We saw that patients’ medical records were secure in all areas.

  • Staff were aware of how to report safeguarding concerns and what to look for when caring for patients.

  • Mandatory training and appraisal rates were variable but on target to be met.

  • A dependency ‘acuity tool’ was used to assess the staffing numbers required.

  • Bank and agency staff filled nursing staff vacancies.

  • Medical staffing was stable and locum cover was arranged as required.

  • Venous Thromboembolism(VTE) assessments were completed in line with national guidance and individual risk assessments were completed and audited.

  • Pre-operative assessments were completed to ensure patients were safe for surgery.

  • Multidisciplinary teams worked well together.

  • Staff were seen attending to call bells promptly.

  • Patients we spoke with told us they had received good cared from friendly staff. They were satisfied that their pain control had been managed well.

  • The average length of stay was below the England average for elective and non-elective surgery

  • Submission to the National 'bowel cancer audit' performance was recorded as 100% in 2016.

  • The trust’s referral to treatment time (RTT) for admitted pathways for surgery, was slightly above the England average, for overall performance since January 2016.

  • Local senior leadership was supportive and visible.

  • Patients and local people were encouraged to get involved in the hospital.

However:

  • Never Events had been reported, however robust measures had been taken to ensure patients safety in the future.

  • Safety thermometer information was recorded but not displayed on the wards.

  • Staff did not hear about other wards complaints so wider learning was not shared.

  • Staff felt listened to when they raised issues, but were less positive about the follow up action taken. Staff felt they were not being included in plans for surgical services.

Urgent and emergency services

Requires improvement

Updated 5 April 2019

Our rating of this service stayed the same. We rated it as requires improvement because:

  • The trust target for mandatory training compliance was not met for nursing or medical staff in some subjects.
  • Staff did not always understand their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They did not always know how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
  • Not all staff were appraised, staff work performance and supervision meetings were not always held to provide support and monitor the effectiveness of the service.
  • At city ED we found that nurses call bell was out of reach and away from patients.
  • Patients privacy during triage at main ED was not always adhered to.
  • The trust did not always plan and provide services in a way that met the needs of local people. There were long waits for acute mental health practitioner and social workers to review patients in ED.

However:

  • There was an incident reporting process in place and staff knew how to report incidents.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • The service had effective systems in place to recognise and respond to deteriorating patients’ needs and clinical risks. Observations of the patients were recorded using the national early warning scoring (NEWS) system, staff demonstrated good understanding of how and when to escalate when a patient deteriorates.
  • Medicines management and documentation were generally good.
  • The service had suitable premises and equipment, and these were well maintained.
  • The service employed nursing and medical staff with the right qualifications and skills to keep people safe.
  • The multidisciplinary team worked well together to support patients holistically.
  • Managers of all levels within the Urgent and Emergency care had the right skills and abilities to run a service providing quality and sustainable care.

Maternity

Good

Updated 5 April 2019

We previously inspected the maternity department at Sandwell and West Birmingham Hospitals NHS Trust jointly with gynaecology. Therefore, we cannot compare our new ratings for this inspection of maternity services directly with the previous ratings.

We rated this service as good because:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.

  • The service controlled infection risk well. Staff kept themselves, equipment and the premises visibly clean. Control measures were used effectively to prevent the spread of infection.

  • The maternity service had systems in place to ensure the safety of patients. Staff appropriately carried out Cardiotocography (CTG) monitoring in line with local policies and guidance.
  • Staff kept appropriate records of patients’ care and treatment. Records were easy to follow, up-to-date and included all the relevant patient information.
  • The maternity service provided care and treatment based on national guidance. Managers checked to make sure staff followed the most up-to-date guidance to ensure patients’ outcomes were the best possible.

  • Staff assessed and managed patient’s pain regularly and effectively. Patients had a number of different pain relief methods available such as epidurals and natural pain relief options including labouring in birthing pools.
  • Maternity staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They understood how to support patients experiencing mental ill health to make decisions about their own care.
  • Maternity staff cared for patients with compassion. Patient feedback confirmed that staff treated them well and with kindness.
  • Staff provided patients and relatives with appropriate information and timely emotional support to minimise their distress.
  • Staff involved patients and those close to them in decisions about their care and treatment. Staff provided patients and relatives with information and advice regarding different birthing settings available to them appropriate to their clinical needs and risks.
  • The trust planned and provided specialist services in a way that met the needs of local people. Specialist antenatal clinics were held in maternity and support was individualised to meet the diverse requirements of the local population.
  • Patients could access the maternity service when they needed it. However, it could take a number of hours for patients to complete their antenatal appointments. This ensured all appointments were conducted on the same day rather than having to return on a number of different days.
  • The maternity service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff. Staff aimed to alleviate patient concerns before they became formal complaints.
  • Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.

  • The maternity department had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.
  • The trust collected, analysed, managed, and used information well to support all its activities, using secure electronic systems with security safeguards.
  • Overall the trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively. However, staff told us the communication regarding the closure of the halcyon birth centre was insufficient.
  • Maternity service leaders were committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

However;

  • The maternity service did not always have enough nursing staff to keep patients safe from avoidable harm and abuse and to provide the right care and treatment. Staff in the Serenity Suite told us they sometimes felt staffing levels were not safe which impacted on the levels of patient care staff could provide. Serenity suite staff felt staffing of the delivery suite took priority over the staffing of the Serenity suite. Staff told us this had put a strain on the relationship between Serenity suite and delivery suite staff. However, we did not observe this during our inspection.

  • We found the fridge used to store breast milk on the antenatal was not secured posing a potential safety risk. We saw evidence the service addressed this in a timely way after we raised this with service leaders as a lock had been fitted to the milk fridge on the antenatal ward.

  • The trust performed about the same as other trusts in the CQC maternity survey 2017. The maternity service performed worse than other trusts for 10 out of 16 questions and about the same for six of the 16 questions.

  • Staff morale was affected by the staffing levels in the department. Staff told us they felt stressed on a daily basis which meant they were looking for employment elsewhere.