Birmingham Children's Hospital

We conducted this inspection from the 17-20 May 2016. We returned to the hospital for an unannounced to see the hospital services outside of core business hours.

This is a specialist trust and we made a public commitment to inspect these before June 2016. We held no other intelligence to have raised the risk to require us to inspect before this date.

We conducted this inspection under our comprehensive methodology, giving the trust notice of our inspection. This enabled us to request information prior to the inspection, review information we held about the trust and speak with stakeholders of the trust. We inspected the main site, based in the centre of Birmingham. We also inspected Forward Thinking Birmingham this is a mental health service offered to young people up to the age of 25yrs. The services offered care both in-patients at Parkview and within community hubs.

Please note the service offered under Forward Thinking Birmingham had commenced fully April 2016 just prior to our inspection. BCH (Birmingham Children’s Hospital) is the lead provider of the service delivered by a consortium. The inspection findings are in separate reports.

Please note when we refer to Paediatric intensive care unit (PICU) we are describing to critical care for children and young people.

We rated the hospital ‘outstanding’ overall;

Our key findings were as follows:

• Staff understood how and the importance of raising incidents. Learning was shared amongst the staff group to keep improving quality.The trust had started to report excellence and sharing learning when things when well.

• Multidisciplinary team working was embedded in the trust.We observed this in action.

• The feedback from parents and children was positive, with them reporting they were treated with respect and dignity.Bereaved parents described the compassionate care they received from the staff.

• Results of surgical outcomes demonstrated the team performed better or the same as comparable services.

• We noted how responsive the trust was, for instance, they were piloting a service with the aim to reduce readmissions to the hospital by having health visitors conduct follow-up calls to patients who had been discharged form ED.

• As the trust served patients and parents from outside of the Birmingham environs, parents were able to use nearby accommodation free of charge.This allowed them the opportunity to stay near by their child whilst they were receiving treatment.They were also able to seek support from other families using the accommodation.

• All cancer referrals met the treatment targets, and 100% of all children were seen within six weeks of referral.

• Safer staffing tool demonstrated there was enough nursing staff to meet patients’ needs supplemented by bank staff.Staffing sickness rates were below the England average.

• The trust had a strategy in place to ensure it met its vision. Systems were in place to ensure the board were aware of any risks that could prevent it from meeting the vision.

• Staff were aware of the values and were assessed against them as part of the appraisal process.

• The leadership was well respected amongst the staff group and were effective, with succession planning in place and a board development programme.

• The culture was one of support of each other, staff referred to ‘Team BCH’, and using opportunities to listen to patients carers and visitors.

• Seven never events had occurred in surgery.This had resulted in the theatre team being investigated internally to try to identify a pattern and areas for improvement.The trust had commissioned an external company to help them identify areas of improvement.A theatre task force was in place to drive the momentum.

• There had been outbreaks of reportable infections, and we saw that improvements were needed regarding hand hygiene in neonatal services.However, we did find most areas to be visibly clean.

• Consultant staffing levels in neonatal did not meet the best practice guidelines.There was a vacancy rate of 26% in child and adolescent mental health services (CAMHS).

• We saw there were a lack of up to date care plans in place for (CAMHS) patients and a lack of outcome data for neonatal services.

• PLACE scores returned demonstrated that patients were not fully satisfied with the food.The trust had done work to improve the food with the support of dieticians and the introduced defined meal times.This included feedback place mats and music for example.

• PICANET data (2014) demonstrated that standardised mortality ratios were within expected range.

We saw several areas of outstanding practice including:

• Within medical care, we saw outstanding use of storytelling therapists to help with children’s emotions, anxiety and distress during their stay in hospital, and to help to explain treatment processes to them.Following a session of storytelling therapy, one parent reported their child had not asked for their usual pain relief overnight.

• On the PICU, a safety huddle (a safety briefing meeting) was held three times throughout the day to review patients and the PICU patient flow.An additional safety huddle was held at 4.30pm during the inspection, as patient demand was greater than capacity, which was attended by the Medical Director who was on call that evening.This was outstanding practice with team involvement for safety.

• The trust has implemented a Rare Diseases Strategy, which will deliver an innovative approach for children who due to their rare or undiagnosed condition would be required to attend multiple outpatient appointments with a variety of specialities.The Rare Disease Centre will enable all clinicians involved in the care of the child to be present to provide a holistic approach in one appointment.

• Transition services demonstrated a service which was actively supporting young people to moveinto adult services.Serviceswere offered both in and out of the hospital, and the multidisciplinary team worked in a cohesive fashionsuch as joint clinics.

• End of life core service supported children and young people and their families during palliative care and at the end of their life.Services were responsive, with referrals accepted within 24 hours. Urgent discharges were achieved within 24hrs so children and young people could die where they requested.

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

Importantly, the trust must:

• The trust must take action to ensure that learning from serious incidents involving neonates ward are shared consistently across the trust.

• Review governance processes to ensure neonatal services assess, monitor and mitigate risks to all neonates across the trust. This should include reviewing the neonatal governance structure and morbidity and mortality meetings.

• Radiology must ensure that a radiologist is always available for advice and for protocolling CT and MRI examinations.

• Within CAMHS community, the trust must ensure there are sufficient numbers of skilled and qualified staff to provide an effective service.

Please note more outstanding practice and ‘must’ and ‘should’ actions can be found at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals