The Care Quality Commission
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Archived: Heart of England NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Requires improvement read more about inspection ratings
Important: Services have been transferred from this provider to another provider

All Inspections

06 September and 18 to 20 October 2016

During an inspection looking at part of the service

The trust had undergone significant changes in senior and executive management due to the trust not meeting nationally identified targets. We used the intelligence we held about the trust to identify that we needed to undertake a responsive inspection of the all three acute sites (Birmingham Heartlands Hospital (BHH), Good Hope Hospital (GHH) and Solihull Hospital (SH)) Emergency department (ED), Medical care, Surgery, Critical care and Outpatients and diagnostic imaging (OPD D). In relation to Critical Care we inspected this service only at BHH as it had been rated good previously and wanted to see if it had improved further. We also inspected some community locations these included the Chest clinic, two dialysis units, Runcorn Road and Castle Vale, and community adult services.

The inspection took place with an unannounced inspection on 06 September 2016 and on that day we gave the trust short notice of our return on 18 to 21 October 2016.We had previously inspected the trust in December 2014; this was due to concerns relating to the trust’s ability to meet national targets. We had also seen changes in the executive team which could have had the risk of unsettling the staff groups.

At that inspection we inspected the domains Safe, Responsive and Well-led. The core services visited during that inspection were ED, Medical care, Surgery (please note, we were not able to give surgery a rating due to an internal CQC issue) Maternity and Gynaecology and OPD DI at all three acute sites. We did not look at any other community services.

We did not inspect Maternity and Gynaecology, the trust had commissioned an independent review which was taking place at the same time. We thought it would be excessive to have two inspection teams putting undue pressure on the staff on the units. We also did not inspect Children and young people and end of life services.

We have not rated the trust overall as we did not inspect the exact same services and domains. We use this report to describe the ratings each core service has achieved and how that compares to the previous inspection.

Please note we have given the Well-led section of the report a rating as we had sufficient information to do so at an overall level.

ED overall rating was; BHH was requires improvement which was better than the inadequate from the 2014 inspection. SH was rated as good which was an improvement from requires improvement that it was rated as in 2014. GHH was requires improvement which was the same as the previous inspection.

Medical Care overall ratings were; good at both BHH and SH; this was an improvement on the previous inspection.

BHH remained the same with a rating of requires improvement.

OPD DI saw both BHH and GHH increasing their ratings to good from requires improvement. SH remained the same with a good rating.

Surgery was rated as requires improvement at BHH and GHH, with good at SH.

Critical Care achieved a good rating at this inspection at BHH.

In addition to this we also inspected a number of community services. These had not been inspected in 2014 and we wanted to inspect these services. We found the following;

Chest Clinic , Runcorn Road Dialysis, Castle Vale Renal Unit and Community adult services were all rated good. This was the case for all domains, with the exception of Runcorn Road Dialysis well-led domain which achieved an outstanding rating.

SAFE

  • Incident reporting and learning was open and transparent. There were systems in place disseminate learning trust wide.
  • Executive root cause analysis meetings took place, where incidents were scrutinised in more detail and was attended by a member of the executive team.
  • We noted the trust delivered the requirements of the Duty of candour and staff had a good understanding of their individual responsibilities.
  • The trust undertook regular infection audits, to identify staff compliance and areas for improvement. During the inspection we did see that some areas needed to improve IPC practice, notably at GHH, where theatre staff were seen outside of the theatre suite in scrubs.
  • Safeguarding adults and children all levels met or exceeded the trust target.
  • The trust undertook mortality and morbidity meetings, where lessons were identified and shared for learning.
  • There were seven active mortality outlier alerts open September 2016. The trust was actively working on identifying the cause and learning.
  • There was a staffing shortfall in nursing, medical and dental, non-clinical staff and allied health professionals. Bank, agency and locum use was high.

EFFECTIVE

  • Evidence based clinical pathways were being used. Policies were written in line with best practice guidelines.
  • Risk assessments were undertaken appropriately. We saw nutrition and hydration assessments, and where identified patients needing support were offered it. This was reinforced by a coloured tray system, as an at a glance process to identify patients needing support.
  • The trust participated in 97% of national clinical audits.
  • The trust did not have Joint Advisory Group (JAG) accreditation, at the time of the inspection. They were working with JAG to regain the accreditation.
  • Multidisciplinary team working was well embedded, and we saw good outcomes for patients and staff as a result. For example, the community the Rapid Response Team working from the community hub brought together MDT to avoid hospital admissions and keep patients safe at home.

CARING

  • We observed staff displayed a genuine interest in patients. We saw that dignity was maintained. However, we did see that due to space constraints in CCU, maintaining privacy was difficult. The use of privacy screens was not always effective.
  • FFT results were lower than then England average, the PLACE scores were for food and cleanliness were high.

RESPONSIVE

  • The Minor Injuries unit at SH used to be a full emergency department. Ambulance services no longer brought patients identified as majors to the hospital, however, the local population needed additional education regarding the service change at that site. Ambulances did bring patients directly to the AMU.
  • SH did have the ability to care for paediatrics until they could safely be transferred, by on site anaesthetist.
  • Access and flow was an issue. Bed occupancy rate was 95%. Discharge arrangements needed to be strengthened, as bed occupancy was high. For instance, a number of patients needed to be cared for outside of CCU due to there being a lack of beds. We also saw medical outliers one of which had not been seen by a doctor for six days from admission.
  • Referral to treatment times did not always meet national targets. However, we did see that was an improving picture.
  • The trust was not meeting its own policy regarding responding to complaints. Following a governance review the trust had worked hard to reduce the backlog of outstanding complaints.

WELL LED

  • The Chair and CEO were interim and put in place to support the trust to achieve national targets and financial stability.
  • There had been changes in the structure of the senior management and divisional structural changes too. Staff were positive about the changes and the visibility of senior management on their units.
  • Staff understood the vision and values and how they contributed to the objectives set by the trust. Staff were involved in identifying the values they worked towards also.
  • The governance structure was organised so that ward to board and visa versa communication was effective.
  • We noted that black and minority ethnic staff were under- represented from band 8 and above and on the board.
  • The trust had implemented a programme to ensure that STAT antibiotics were given within an hour of prescribing. The programme was a success and had been rolled out to include Parkinson medication, with good results.

Areas of outstanding practice include:

  • The trust approach to an ‘Executive Root Cause Analysis’ meeting where robust professional and management challenge is centred on supporting learning from incidents.
  • The trust employed a nurse educator for the ED specifically to ensure nursing staff are competent practitioners. Newly qualified staff had a local induction and a period of preceptorship. Newly qualified staff that we spoke to told us that they received very good support.
  • We saw an example of outstanding practice in the imaging department. There was an excellent induction document introduced by senior imaging managers. This gave radiographers opportunities to reflect on their practice and innovative ways of thinking about how they work. After staff had completed the induction, a discussion took place between the radiographer and the on-site lead. This also ensured staff had the necessary knowledge to practice safely.
  • Infection prevention and control practices at the Runcorn Road Dialysis unit were systematic, thorough and embedded. The unit and its equipment were spotlessly clean.
  • Tuberculosis services had received national recognition for their work in decreasing the number of failed appointments and improving engagement of patients from certain minority groups.

The trust MUST:

  • Improve infection prevention and control practices amongst its staff in some locations.
  • Within the emergency department at BHH the trust must ensure that the premises is suitable for the service provided, including the layout, and be big enough to accommodate the potential number of people using the service at any one time.
  • The trust must consistently ensure medicines are stored appropriately and are suitable for use.
  • The trust must ensure staff are trained and competent to administer medicines under PGDs.
  • The trust must review and improve security and access arrangements at the at Castle Vale Renal Unit.
  • The ED at Good Hope Hospital must ensure they follow policies and procedures about managing medications; including storage, checking medications are in date, and safe disposal of medications.

The trust SHOULD:

  • Improve its BME representation at senior management levels within the organisation.
  • Staffing levels did not meet the trust’s agreed establishment. The trust should ensure sufficient staff (medical and nursing) in its substantive establishment to avoid the overreliance on agency staffing.
  • Improve its response to complaints to meet the targets the trust has set itself.
  • Continue to improve its board governance process; particularly with regard to the board assurance framework and board visibility of lower level risks.

Please note all the ‘Musts’ and ‘Shoulds’ can be found at the end of the report.


Professor Sir Mike Richards

Chief Inspector of Hospitals

18 to 20 October 2016

During an inspection of Community health services for adults

We judged that community adult services (CAS) were good.

  • Community adult services (CAS) achieved a good standard of safety. This was because there were good methods of reporting, investigating and learning from incidents and near misses that were well understood by staff and embedded in their daily work. There were plans to deal with major incident or events that would disrupt the delivery of care. CAS staff were making appropriate adult safeguarding referrals. There were processes and systems that protected patients from the risk of infection, and the risks associated with equipment used in their care and treatment. There were safe systems of medicines management. Records were accurate, comprehensive and current, and supported the delivery of safe care. Most mandatory training had been completed across CAS against a trust target of 85%. Staffing numbers were reviewed regularly, an active recruitment programme was in progress and arrangements to ensure any staffing shortfalls were managed on an on-going basis to minimise the impact on patients.

  • National guidance from government, the National Institute of Health and Care Excellence (NICE) and professional bodies were complied with and that staff showed awareness of relevant guidance in their work. Staff were actively engaged in activities to monitor and improve quality and outcomes. Quality of care was monitored through audits, which informed the development of local guidance and practice. Patients could access all professionals relevant to their care through a hub system of integrated multi-disciplinary teams (MDT). Patients’ care was co-ordinated and managed. There were systems to gain people’s consent prior to care and treatment. Where patients lacked the capacity to give consent, there were arrangements to ensure that staff acted in accordance with their legal obligations.

  • Patients and carers were positive about their experience of care and treatment, and feedback gathered by the organisation showed good levels of satisfaction. The average score for people who responded that they would be likely to recommend community services was 98%. We observed all staff responding to people with kindness and compassion. Patients told us they were treated with dignity and respect, and that they were involved in the planning and delivery of their care to the extent they wished to be.

  • The involvement of other organizations and the local community was integral to how services were planned and ensured that services met people’s needs. CAS had a model of integrated community hubs to ensure people received joined up working that was responsive to their individual needs. There was provision to ensure that essential services were available out-of-hours, and there were no major issues with waiting lists, with the exception of podiatric surgery, where a few patients exceeded the 18 week wait target due to a lack of available anaesthetists.

  • Work was in progress to give community adult services a clear strategic direction and staff felt engaged with the strategy development. There was evidence of innovative practice including podiatric staff working in a MDT in dermatology for patients with  epidermolysis bullosa (EB), an inherited genetic condition that makes skin fragile.
  • The leadership drove continuous improvement and staff were accountable for delivering change. There was a clear proactive approach to seeking out and embedding new and more sustainable models of care, for example a model of community hubs. There were systems to ensure good governance and monitoring of standards and performance. There was an effective escalation and cascading of information from the board to front-line workers, and vice-versa. We found that there was a positive culture, with staff and managers feeling proud of their work and achievements and speaking well of their colleagues and leadership.

08-11 December 2014

During an inspection looking at part of the service

Heart of England Foundation Trust is a large NHS provider of acute hospital and community services in Birmingham and Solihull. The hospitals are in the East and North of Birmingham and one smaller site in Solihull West Midlands. There is also the Birmingham Chest Clinic which is in the centre of Birmingham. The trust has some community services in Solihull. We did not inspect the community services or the Chest Clinic. The three acute sites are Birmingham Heartlands Hospital, Good Hope Hospital and Solihull Hospital. Along with the community service the trust serves approximately 1.2m people. The Birmingham Heartlands site is where the trust headquarters are located.

We carried out this unannounced responsive inspection because the trust was in breach with regulators Monitor, and we had received intelligence which warranted our response and so we arranged the inspection. The inspection took place between 08 and 11 December 2014. We had inspected the service in November 2013 and the trust was still working through compliance action plans. While progress has been made since our last visit, this is limited and not yet sufficient.

We specifically focussed on A&E, Medicine, Surgery, Maternity and Outpatients Departments on all three sites.

This inspection was an unannounced responsive inspection. The purpose of the report is to share with the trust and the public the evidence we gathered during that inspection. It is also important to note that at the time the trust leadership was in transition with many changes within the trust executive team, some of whom were in interim posts. This had been precipitated by the previous Chief Executive resigning in November 2014.

While we found some evidence of progress since the last inspection we did find in others no improvements or deterioration.

Our key findings were as follows:

  • Widespread learning from incidents needed to be improved.
  • Appraisals for staff were not widely undertaken achieving 38% compliance at the time of our inspection; which would equate to 57% by year end.
  • Staffing sickness and attrition rates were impacting negatively on existing staff.
  • The poor patient flow mainly in BHH and GHH was having negative impacts across all the core areas we inspected. For instance the number of patients having to wait in recovery more than 30 minutes was high.
  • Referral to treatment times were not always met for people. It was present on the Board assurance framework and posed a reputational risk to the trust as well as a risk to patients waiting for treatment.
  • Discharge arrangements required improvement; we saw that only 35% of patients were discharged on or before their planned date of discharge.
  • The care of the deteriorating patient was generally managed well.
  • Arrangements for patients with reduced cognitive function were not always effective. This meant that some patients did not receive the level of care and support they required.
  • The leadership was in a transition phase with some in interim posts including Chief Executive and Medical Director.
  • The culture within the trust was one of uncertainty due to the number of changes which had occurred.
  • Staff could not communicate the trust vision and strategy.
  • Governance arrangements needed to be strengthened to ensure more effective delivery.
  • IT systems needed to be improved to ensure reporting was accurate. The ability of the trust to report against activity was not always available for use at trust level or to their commissioners.

We saw several areas of outstanding practice including:

  • On the Acute Medical Unit (AMU) at Birmingham Heartlands Hospital (BHH) local complaints resolution was very responsive to patient’s needs. The complainant was invited to a meeting and given a recording of the discussion. This appeared to resolve complaints quickly.
  • AMU, Ambulatory Care, wards 10, 11 and 24 on the BHH site provided excellent local leadership, services were well organised, responsive to patients individual needs and efficient which resulted in excellent patient outcomes.
  • The Practice Placement team provided excellent links between the trust and the University in supporting more than 600 student nurses across all three hospital sites.
  • Sexual health team demonstrated how they used information such as audit and patient feedback to improve services to patients.
  • We saw caring was good across the trust. We did not review caring in this report; but had no concerns about the caring of staff in the trust.

However, there were also areas of poor practice where the trust needs to make improvements.

  • BHH Emergency department was overcrowded with poor flow, leading to a high stress, high risk environment for both patients and staff.
  • Arrangements for patients who required mittens were not undertaken to maintain patient’s safeguards. The hospital staff was applying mittens to some patients (to prevent removal of nasogastric tubes etc) without the necessary Deprivation of Liberty Safeguard assessments being in place.

Importantly, the trust must:

  • The trust must take effective action to achieve consistent staff compliance of infection control procedures within the emergency department.
  • The trust must address the ambivalence held by staff about reporting incidents as they may be underreporting and trust could miss important trends.
  • The trust must ensure that staff are clear about clinical responsibility for patient’s awaiting handover by Ambulance services in the emergency department at Heartlands.
  • The trust must take effective action to address the crowding in the majors area of the ED department and ensure that staff on duty can see and treat patients in a timely way.
  • The trust must ensure all patients requiring items of restraint such as hand control padded mittens are supported with a mental capacity assessment, a DoLS and are regularly reviewed by the MDT which is recorded in the patient’s notes and mittens are replaced when soiled. A consistent practice must be adopted across the trust.
  • The trust must replace or repair essential equipment in a timely manner.
  • The trust must provide sufficient staff to operate the second obstetrics theatre at night, and prevent delays occurring.
  • The hospital must improve the information available to outpatients departments to ensure that these are monitored and action taken to improve services through audit, trending and learning.
  • The trust must review the operation of rapid assessment of patients to improve its consistency and effectiveness.
  • Improve the environment of the transfer corridor used to transport patients and dispose of refuse appropriately at the Good Hope site.
  • The trust must improve arrangements regarding patients following surgery having to wait in recovery over 30 minutes.
  • The trust must ensure all fire doors and exits are free from clutter.

There were also areas of practice where the trust should take action, and these are identified in the report.

As a result of this, the trust will be subject to regulatory action as requirement notices and a comprehensive inspection will be carried out to confirm this.

Professor Sir Mike Richards

Chief Inspector of Hospitals

11-15 Nov 2013 and 27 Feb 2014

During a routine inspection

The Heart of England NHS Foundation Trust is one of the largest hospital trusts in England. It provides general and specialist hospital and community care for the people of East Birmingham, Solihull, Sutton Coldfield, Tamworth and South Staffordshire. The trust comprises four main locations: Birmingham Heartlands Hospital, Solihull Hospital, Good Hope Hospital and Birmingham Chest Clinic. These also provide community health services across the borough of Solihull and run a number of smaller satellite units, allowing people to be treated as close to home as possible.

The trust has a directorate structure in which each hospital location is a directorate with defined responsibilities. However, the corporate services, which include theatres and critical care, and the women’s and children’s directorate are run centrally and cut across the individual locations.

We inspected this trust as part of our new in-depth hospital inspection programme. It was being tested at 18 NHS trusts across England, chosen to represent the variation in hospital care across England. Before the inspection, our ‘Intelligent Monitoring’ system indicated that the Heart of England NHS Foundation Trust was a medium-risk trust. The trust had a longstanding history of struggling with its turnaround times in the A&E department. The management team had put in place a number of initiatives to reduce the amount of time people were waiting in A&E, but this had not yet had an impact.

The Heart of England NHS Foundation Trust has been inspected 17 times across its different locations since registration with the Care Quality Commission in 2010. The most recent inspection, at Good Hope Hospital, took place in July 2013. This hospital was found to be meeting all inspected standards.

Before visiting, we looked at the wide range of information we held about the trust and asked other organisations to share what they knew about it. We carried out announced visits between 11 and 15 November 2013 to Birmingham Heartlands Hospital, Good Hope Hospital and Solihull Hospital. At each site we held focus groups with different staff members from all areas of the hospital. We looked at patient records of personal care or treatment, observed how staff were providing care, and talked to patients, carers, family members and staff. We reviewed information that we had asked the trust to provide. Before the visit, we met with four local groups of people to gain their experiences of the trust and during the inspection we held three listening events, one near each hospital location, so that we could seek the views and experiences of people using the service. We spoke to more than 60 people through these listening events. We also carried out an unannounced inspection on 23 November 2013.

We undertook a focused inspection on 27 February 2014 to review the trusts compliance with the warning notice we served at Good Hope Hospital on 20 December 2013. This report has been updated to reflect our findings at this latest inspection.

The trust was below the national average in the Friends and Family Tests introduced in both A&E and inpatients.This means that patients the numbers of patients who were likely to recommend the trust to a family member or friend was low. This was in contrast to the positive feedback from patients during the inspection who felt that, overall, care was responsive and provided in a sensitive and dignified manner, despite caring staff being busy.

The trust had reported five ‘never events’ in the past year, which was higher than similarly sized trusts. The inspection team looked at the systems and processes in place to minimise never events, and noted evidence of good practice such as implementation of World Health Organization safe surgery checklists. The team also looked at ways in which the trust implemented the lessons learnt from these events throughout the hospital. 

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.