All inspections: Good Hope Hospital - Care Quality Commission

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 hospital to identify that we needed to undertake a responsive inspection of the Emergency department (ED), Medicine, Surgery, and Outpatients and diagnostic imaging.

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 did not inspect Maternity and Gynaecology, the trust had commissioned an independent review of the service, this was taking place at the same time as our announced inspection. We decided that it would be too onerous on staff to have two inspection teams at the same time. We also did not inspect critical care, children and young people and end of life services.

We have not aggregated the rating for the hospital, but for the core services only. We did not inspect all the core services or the same core services as previously. You can see the rating comparison of services in the provider report.

During the inspection we saw both ED and surgery medication management needed to improve. The storage of and checking of medications did not ensure the efficacy of medicines and ensure patient safety.
Infection prevention control needed to improve in both ED, surgery and outpatient department. There were bloodstains seen in some areas and on some resuscitation equipment in the ED. In addition, screening for infections prior to surgery was not consistent. We saw that hand hygiene audits were not completed in outpatients. Although we did observe good handwashing and gel use appropriately.
The ED was not meeting national targets to admit, transfer or discharge within four hours.
Staffing was an issue in medicine services, being consistently below planned numbers.
Sepsis management needed to improve, as staff were not following the guidance.
Discharge arrangements for some patients were not always effective leading to delays. This did include lack of provision in the community, but also the planning and management within the hospital needed improvement.
Within surgery, we noted that some national audits demonstrated that they were performing below the England average.
The patient flow within surgery had delays at every point, including the return to the ward following surgery.
Services for vulnerable people did not meet their needs in surgery. For example, the records relating to deprivation of liberty safeguards, were not well completed.
Feedback to staff relating to incidents and outcomes was not always delivered in outpatients.

However;

Incident awareness and reporting was good within the hospital.
The handover process in ED was excellent, this included education development by senior staff.
A safe patient protocol was in place and being used when patients were being cared for in corridors when the department was full.
Junior members of staff were well supported, staff told us about the positive teamwork.
The ED had employed a flow coordinator, to improve the time that patients were seen.
Within the medicine directorate, surgery and outpatients the safeguarding awareness in staff was good, in line with the trust policy.
There was good clinical leadership seen in surgery. Medical assessments and risk assessments were completed and reviewed effectively to inform patient care.
Friends and family test results were above the England average in surgery. Feedback from patients mostly described the compassionate care they received.
Within the outpatient department, we saw that the ‘I am clean’ stickers were used effectively.
Medications and prescriptions were stored safely.
Staff within diagnostic imaging complied with the policies relating to the Ionising Radiation (Medical Exposure) 2000 regulations IR(ME)R.

We saw several areas of outstanding practice including:

ED:

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.

Outpatients and diagnostic imagining:

We saw some excellent examples of innovation. In diagnostic imaging an induction pack had been introduced for the radiographer to reflect on their practice. Following completion of the induction, a discussion took place between the radiographer and the on-site lead. This would provide the radiographer with the opportunity to reflect on their role and ensure they had the knowledge to practice safely.

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

Importantly, the trust must:

ED:

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 ED must ensure that cleanliness standards are maintained throughout the department in order to ensure compliance with infection prevention and control requirements.

Surgery:

The trust must consistently maintain medicines within their correct storage conditions to ensure medicines are suitable for use.

In addition the trust should:

ED:

The ED should continue to monitor the management of complaints for Good Hope Hospital, ensuring these are investigated and managed within trust timescales.
The ED should ensure that all appropriate patients receive a risk assessment relevant to their individual needs upon entering the department; for example falls risk assessments.

Surgery:

The trust should ensure compliance with the Mental Capacity Act (2005) is documented.
The trust should take action to improve adherence to infection prevention and control procedures
The trust should ensure patients have timely access to pressure relieving equipment suitable for their needs.

Outpatients and diagnostic imaging:

The trust should ensure local rules for lasers are signed and in date.
The trust should ensure service records for lasers in ophthalmology are up to date and accessible for relevant staff.

Please note the full list of ‘Must’ and ‘Shoulds’ can be found at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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.

This inspection was an unannounced responsive inspection and as such we will not be rating the service. 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 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.

Our key findings were as follows:

Widespread learning from incidents needed to be improved.
Appraisals for staff were not widely undertaken achieving 28% compliance at the time of our inspection.
Staffing sickness and attrition rates were impacting negatively on existing staff.
The congestion within the hospital 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.
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 many in interim posts.
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 reporting needed to be improved to ensure reporting was accurate.

We saw several areas of outstanding practice including:

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.
AMU, Ambulatory Care, wards 10, 11 and 24 provided excellent local leadership, services were well organised, responsive to patients individual needs and efficient which resulted in excellent patient outcomes.

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

Incident report feedback needs to be improved so that staff are accessing the learning opportunities.
Appraisals need to be undertaken for staff and supervision to improve staff development.
Arrangements for patients who required mittens were not undertaken to maintain patient’s safeguards.

Importantly, the trust must:

The trust must take effective action to address the overcrowding in the majors area of the emergency department and ensure that staff on duty can see and treat patients in a timely way.
The trust must review the operation of rapid assessment of patients to improve its consistency and effectiveness.
The trust must take effective action to achieve consistent staff compliance of infection control procedures
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 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.

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

The ratings in this report were awarded as part of a pilot scheme to test CQC’s new approach to rating NHS hospitals and services.

Good Hope Hospital is the second largest of the three hospital locations run by the Heart of England NHS Foundation Trust. It provides general and specialist hospital and community care for the people of East Birmingham, Sutton Coldfield, Tamworth and South Staffordshire. Good Hope Hospital has approximately 521 beds and is a centre for pain management.

We inspected this trust as part of our new in-depth hospital inspection programme. This programme is 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 accident and emergency (A&E) department. The management team had put initiatives in place to reduce the amount of time people were waiting in A&E but these had yet to have an impact. These included escalation plans, bed management meetings, use of discharge boards to name a few. We did not inspect any community services provided.

This hospital has been inspected seven times under the previous methodology. The first inspection took place in March 2010 and the hospital was found to be meeting the inspected standards. The next inspections took place in April and August 2011 and the latter inspection found the hospital to be not meeting the standard on the management of medicines. Follow up inspections in 2012 found the hospital to be meeting all inspected standards. The last inspection was in May 2013, following previous non-compliance in January. The hospital was meeting the inspected standards.

Before the inspection, we looked at the wide range of information we held about the trust and asked other organisations to share their knowledge and experience of it. We carried out announced visits between 11 and 14 November 2013 to Good Hope Hospital. We looked at patient records of personal care or treatment, observed how staff were providing care, and talked with patients, carers, family members and staff. We reviewed information that we had asked the trust to provide. Before visiting, 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 issued a warning notice to the trust on 20 December 2013 in respect of following national and local guidance and policy. We reinspected to monitor compliance with this notice on 27 February 2014. We found that the trust was compliant in respect of the issues contained within the warning notice. Where this follow up inspection reviewed issues at the trust this report has been updated to reflect this.

The trust scored below average in the Friends and Family Tests introduced in both the A&E department and for inpatients. However, during the inspection, we heard positive feedback from patients who felt that, overall, care was responsive and provided in a sensitive and dignified manner despite caring staff being busy.

In general, we found the surgical and critical care services at Good Hope Hospital to be responsive to the needs of the people it served. However, we were concerned about the nursing staffing arrangements in maternity, children’s care, medical care and A&E. These presented in different ways and had different impacts on patients in these areas.

In A&E, the initial triage was not followed up by a medical triage, which had an impact on potentially ill patients not being seen in a timely manner. The care given in this area was poor because of the time pressures on nursing staff. Within the medical unit, the care given to patients mostly met their needs, but on the acute medical ward (Ward 20) there was a lack of basic furniture such as lockers and chairs, regular nursing staff and security of medicines that led to the service being unsafe. We raised this at the time of our visit with both the senior manager on site and the chief executive of the trust.

On our return unannounced visit in November 2013, the equipment had been put in place. However, the other issues remained unresolved. We issued the trust with a warning notice in this respect on 20 December 2013. We returned to monitor compliance with the warning notice on 27 February 2014 and found the trust to be compliant.

In maternity and in children’s care, we found that the shortages of staff had an impact on the care of women and children. Midwives were stretched to deliver good care because there were too few of them on duty, and in the children’s services a lack of doctors and staff with appropriate training had an impact on the safety of the service.

The trust was aware that there was a shortage of nursing staff, and that this had had an impact on the care given to patients. It had decided to make it easier to recruit band 5 nurses and band 2 staff by quicker approval of vacancies, and by introducing a rolling programme of recruitment. This was beginning to have an effect in some of the ward areas; however, the full impact of this recruitment programme may not be felt until early 2014. In the meantime, patients and staff said that shortages of nursing staff were preventing people from receiving good treatment and care.

We visited Good Hope Hospital to follow up concerns raised at our inspection in February 2013. These concerns were about the lack of dignity and respect given to some of the patients we spoke to and observed during this visit We also had concerns about the lack of information available to patients informing them of how to make a complaint about the hospital.

For this follow up inspection we visited Ward 11 dementia care, Ward 12 elderly care, Ward 16 surgical and Ward 20. We spoke to 32 patients, 12 staff and two relatives. We spent time observing the interactions between staff and patients on all four wards.

We saw patients being treated with respect and their dignity was maintained. Staff spoke to patients compassionately and responded to their needs appropriately. Explanations were given prior to procedures being carried out.

Patients and relatives told us: 'Everything is spot on, even down to the cleaning' 'The doctors and nurses have explained everything and been in communication with my children' 'The staff are more then helpful' 'They make time for you, I don't know how but they do' 'The care is exemplary'.

We saw posters showing the new complaints procedure on display around the hospital. On two of the four wards we visited booklets were available for patients and relatives explaining the complaints process. The booklets included a complaints form for completion. There was also an easy read version available.

There was a mixed reaction from the patients we spoke to. Some knew how to make a complaint, others did not. Some patients had not seen the complaints booklets but told us they would speak to staff if they had any concerns. They told us: 'I've read the information' 'I don't know the procedure but I would talk to staff if I had any concerns'.

We spent time on ward 11, an elderly medicine ward. We observed patients' experience during lunchtime meal service on ward 12, another elderly medicine ward. We spoke with patients on ward 20, an acute medical unit which accommodated male patients for short stay periods while their condition was being assessed. We also spent time on ward 16, a surgical ward.

During the course of the day we spoke with 37 patients and four of their relatives. We also spoke with ten nursing and healthcare staff. We met with senior staff from the trust's patient engagement and patient services. We met with the hospital's safeguarding leads for adults and children. We spoke with a member of the hospital social work team.

We found that patients' views and experiences were not always taken into account in the way the service was provided and delivered in relation to their care. For example, we saw several occasions when patients were distressed because they had to wait too long for assistance to use the toilet.

We found that patients were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

We found that information about the complaints process was not readily available, understood or well publicised. This meant patients and those acting on their behalf could not be confident their comments and complaints would be listened to and dealt with effectively.

During our inspection we visited three wards, the discharge lounge and the Accident and Emergency department. We talked to nurses and patients and their relatives. Patients we met were generally happy with the care they had received and praised the nurses. One patient said 'Because staff are busy communication is not always as good as it could be.' Another patient said 'Different doctors tell you different things.'

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

We visited the maternity areas of the hospital. We also visited the discharge lounge to look at the discharge arrangements for patients. We visited wards from which patients had recently been discharged and these included wards for older people and those with complex needs.

We spoke to eight women who had recently given birth at the hospital and they were pleased with their care. Women said that they felt well supported by staff. Women told us that they had confidence and trust in the staff caring for them during the labour and birth. One said, 'they were brilliant even the trainee'.

We spoke to four women who were staying in the hospital prior to the birth of their babies. They told us, 'I've had a lovely time'..staff are helpful, friendly, and informative. My husband was made welcome. The hospital is very clean', 'I feel confident that everything is OK. I am being monitored. The staff are helpful and I trust them. I feel confident and even trust the student nurses.

Women who had experienced complications during their pregnancy or delivery praised the staff for remaining calm and professional. They said that staff had supported them when changes to their birth plans had been needed.

Women who had given birth to their older children at Good Hope told us that the standard of care had improved.

Women suggested that the ante natal clinic could be improved by having more chairs, toys for children to play with and better communication about what was going on when there were delays.

Patients in the discharge lounge told us that they had been well cared for during their stay. They said that staff had told them which symptoms to look out for when they arrived home and they had been shown how to use any equipment, such as oxygen. Staff had made sure that they had telephone numbers for relevant helplines. One patient told us that they used the hospital frequently and had seen a 'vast improvement' recently.

We talked to patients about their medicines across a range of locations within the hospital.

A person we met on one ward said 'The staff have been really friendly and accommodating. I've received loads of information about my medicines'

Another person said they were not sure why changes had been made to their medicines.

One person told us that she had waited for four hours in the discharge lounge, for her 'take home' medicines the last time she had been in hospital. She said that the discharge lounge nurse gave her the medicine she needed during her wait. This person had brought her medicines with her into the hospital when she was admitted this time. She said she had self-administered some of these medicines; she had told the ward staff but they 'didn't take any notice'.

Two other people said that they had only waited for a short time in the discharge lounge. All the people we spoke to said that their medicines were checked when they arrived to make sure that the right medicines were prescribed in hospital.

Several patients and members of staff made suggestions about how services could be improved. We passed these on to the trust.

People we spoke to were mostly positive about their experiences of care and treatment on both wards. They told us that they were treated with respect.

On one ward we received some comments that indicated that not everyone was being respected and their dignity maintained.

One person told us 'Staff were busy, reasonably polite but on one occasion they were not very nice. They didn't always talk quietly and this made her feel cross and feel like shouting back.'

Another person told us they were satisfied in the main but were concerned about the length of time they had to wait before being taken to the toilet. They had spoken with staff and it had improved since.

Most people told us that they were happy with the food they received. The food was not too bad and they got enough to eat. We were told that there were choices of hot and cold food on the menu. Some people told us that they hadn't been asked what their likes or dislikes were but had been asked about allergies and if they were vegetarian.

One person told us 'Sometimes the food was not that warm as the trolley started (to serve food) at the other end of the ward but the food was still enjoyable.'

Another person told us 'They always tell me to eat meals, and if I want something else they give me a sandwich. Never been a big eater but we have three meals a day and supper with a drink.'

A relative told us that they came twice a day to feed their father and the food was 'excellent' and they couldn't fault the staff.

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.

Archived: Good Hope Hospital

All Inspections

20 October 2016

During an inspection looking at part of the service

08 -11 December 2014

During an inspection looking at part of the service

Professor Sir Mike Richards

8 December 2014

During an inspection of this service

11 November 2013

During an inspection

11-15 Nov 2013 and 27 Feb 2014

During a routine inspection

17 May 2013

During an inspection looking at part of the service

5 February 2013

During a routine inspection

19 June 2012

During an inspection looking at part of the service

22 March and 18 September 2012

During a themed inspection looking at Termination of Pregnancy Services

10 August 2011

During an inspection in response to concerns

11, 13 April 2011

During a themed inspection looking at Dignity and Nutrition

14 September 2012

During an inspection looking at part of the service