Sandwell General Hospital

Updated 5 April 2019

Sandwell and West Birmingham NHS Trust (SWBH) aspire to be an integrated care organisation. The trust employs around 7,500 people and spends around £430m. The trust is responsible for the care of 530,000 people from across North-West Birmingham and three localities across Sandwell; Wednesbury and West Bromwich, Smethwick, Oldbury, Rowley Regis and Tipton. 

There were 218,904 attendances including General Practitioner (GP) streamed patients last year and achieved 83.38% against the four hour standard. The trust admitted over 40,000 patients as emergencies last year which was a significant rise. They deliver 109,000 outpatient appointments and procedures annually as well as 8,000-day case and elective treatments

SWBH provides care from Sandwell General Hospital in West Bromwich. Sandwell General hospital has a total of 383 winter inpatients beds which reduce during the summer months to 355.

Inpatient paediatrics, general surgery, and stroke specialist centre are located on the Sandwell site. The trust has academic departments in cardiology, rheumatology, ophthalmology, and neurology. The community teams deliver care across Sandwell providing integrated services for children in schools, GP practices and at home, they provide both general and specialist home care for adults, nursing homes and hospice locations.

Updated 5 April 2019

Our rating of services stayed the same. We rated it them as requires improvement because:

• Our rating of safe was requires improvement overall. Nursing and medical staff were not always available in sufficient numbers to provide safe care and treatment. Mandatory for some nursing and medical staff did not meet trust targets. Systems for protecting patients from the risk of the spread of infection were not robust. Patients records were not always updated or kept securely.
• Our rating of effective went down to requires improvement overall. Staff did not always understand their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. Not all staff were appraised, staff work performance and supervision meetings were not always held
• Our rating of caring remained as good overall. Staff treated patients with compassion and kindness.
• Our rating of responsive improved to good overall. The trust did not always plan and provide services in a way that met the needs of local people. Not all services always took into account the individual needs of patients. People could not always access services when they needed to.
• Our rating of well-led remained as requires improvement overall. Managers did not always have the dedicated time and skills to lead services. There was not effective systems for identifying risks managing and planning to mitigate or reduce them. Processes were not always in place to promote learning and continuous improvement. The IT systems in place were fragile and did not support staff to deliver patient care.

Updated 5 April 2019

Our rating of this service went down. We rated it as requires improvement because:

• Leaders did not consistently demonstrate the skills, knowledge and experience needed to carry out their role.
• We saw that some issues raised on our previous inspection in 2017 had not been resolved.
• Resuscitation trolleys were not tamperproof and the risks around this were not sufficiently mitigated.
• We visited the acute medical unit (AMU) and found there were several mixed sex breaches (bays with male and female patients) where patients were not receiving specialised care, some of these were avoidable.
• The service had not provided mandatory training in key skills to all staff and made sure everyone completed it.
• The service did not always have enough nursing staff with the right qualifications, skills, training and experience to provide the right care and treatment.
• It was not always clear how staff had reached decisions that patients lacked the capacity to make decisions about their care and treatment.
• We were not assured of the effectiveness of the trust infection control practices.
• Systems and processes in place to monitor ongoing risk were not always robust or effective.
• The Friends and Family Test response rate at Sandwell Hospital was worse than the national average.
• The average length of stay was worse than the England average in some areas.
• The time it took the trust to investigate complaints, was not in line with the trusts complaints policy.
• The trust did not always manage and use information well to support all of its activities
• Actions needed to improve were not always recorded in action plans.

However:

• The hospital collected information about patient care and took part in national and local audits.
• Staff were knowledgeable around safeguarding and there were safeguarding policies and procedures in place.
• Staff in the endoscopy department were decontaminating reusable scopes in line with national guidance. The department was Joint Advisory Group (JAG) accredited.
• Processes were in place to assess, audit and respond to patient risk. For example, staff monitored patient’s ongoing risk.
• Staff identified and responded appropriately to the changing risks of people who used the service such as deteriorating patients.
• There were systems and processes in place for staff to report incidents. Staff were confident in reporting incidents. There were no recent Never Events.
• The trust took part in local and national audits.
• Most patients were happy with the care staff provided, patients and relatives were provided with emotional support.
• Staff understood patients and involved those close to them; information was available for patients and their relatives.
• Governance structures were in place. Leaders carried out audits to assess performance and shared findings.

Updated 5 April 2019

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

• 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, in line with the Royal College of Nursing 2013 guidelines.
• All ward managers had to cover clinical shifts in order to fill gaps in the rota.
• Staffing did not meet the meet the Royal Colleges of Nursing guidelines that state that children aged over two years old should have one nurse to four patients. This risk increased when HDU patients were admitted to Lyndon 1.
• Unregistered band 4’s were being used in registered staff roles.
• Staff regularly worked over their hours to support their colleagues and often worked without breaks.
• Medical staffing levels did not meet the requirements of the Facing the Future: Standards for Acute General Paediatric Services. The service did not have a consultant paediatrician present and readily available during times of peak activity, seven days a week. Not every child admitted to a paediatric department with an acute medical problem was seen by a consultant paediatrician within 14 hours of admission.
• Arrangements in place to provide annual mandatory training to all members of staff were not effective. The service did not meet the Royal college of Nursing guidelines in relation to staff training in advanced paediatric life support.
• The children and young peoples service could not assure itself of its equipment cleanliness.
• The trust was using ‘ligature free’ rooms to care for children and adolescents with mental health issues, these rooms contained ligatures.
• There were out of date medicines (including controlled drugs) found during this inspection. Staff on Priory Ground only record fridge temperatures for the days the ward is open putting patients at risk of ineffective medicines.
• Staff do not have the skills or training to competently care for CAMHS patients. At the time of this inspection staff did not receive any training in mental health conditions, learning disability or autism.
• The trust employed 2 play specialists who worked across the sites. They were not available seven days a week.
• During our previous inspection of the service in October 2014 we found there was no formal agreement with the local children and adolescent mental health services.
• Staff were not aware of how they routinely received learning from complaints.
• Leaders did not have protected time to carry out their managerial duties. Leaders told us they were not always supported by their managers.
• There was no children’s strategy at the time of our inspection and inadequate support for business planning.
• Staff wellbeing was a concern due to staff shortages. Staff worked excessive hours and when they had physical ailments.
• The trusts risk register was not complete and we could not be assured what actions were being taken to mitigate risks.
• There was no engagement with patients, their families or carers.
• Staff told us they did not feel actively involved in change in the organisation.

However:

• 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.
• Staff followed the trust’s infection prevention and control policy and procedures.
• The children and young peoples services were provided in an environment that was suitable for the services provided.
• We saw resus trollies were checked daily. Equipment contained within these trollies was in date and complied with national standards.
• The children’s wards recorded and appropriately actioned patient risk levels. The ward had good links with child and adolescent mental health services (CAMHS) to see patients with mental health needs.
• The children’s wards routinely used a paediatric early warning score (PEWS) in order to enable the nurses in recognising and responding to signs of deterioration, thereby preventing serious adverse events.
• Individual nursing and medical records were written and managed in a way that kept people safe.
• Incidents were reported by staff working in the service. Staff were more aware of incident investigation processes than they were at our last inspection.
• We saw that staff complied with evidence based practice within their work and completed audits to monitor the quality and efficiency of children and young people services at the trust.
• Treatment was delivered in line with National Institute for Health and Care Excellence (NICE) guidelines for example the trust had guidelines for fluid management, sepsis and asthma.
• Patients nutrition and hydration needs were met on the ward.
• Patients pain levels were recorded and managed appropriately.
• The service monitored, and had low, re-admission rates.
• Necessary staff, including those in different teams, services and organisations, were involved in assessing, planning and delivering care and treatment.
• The service encourages patients to manage their own health and national priorities to improve the populations health are supported.
• Staff understand and respect the personal, cultural, social and religious needs of people and take these into account in the way they deliver care.
• Patients, their families and carers were given emotional support during their hospital admission.
• Psychological services were involved with supporting children and young people on the wards.
• Staff communicated with people so that they understood their care, treatment and condition and any advice given.
• The environment was designed to meet the needs of the people who used it.
• One parent is permitted to stay overnight with the patient and there are family rooms available on both Lyndon 1 and Lyndon Ground.
• Staff described how they could arrange translation services for patients whose first language was not English. Staff also told us how they could access information leaflets on the intranet in languages other than English if required.
• The service cancelled minimum clinics and surgeries with less than 24 hours notice.
• Complaints were handled in a timely and sensitive manner.
• Ward managers were visible and approachable.
• Ward staff worked effectively as a team and felt supported by their ward managers.
• The service has a clear governance structure for paediatrics.
• The trust held Quality Improvement Half Days where learning was shared.

Updated 5 April 2019

Our rating of this service improved. We rated it as outstanding because:

• People were protected from avoidable harm and abuse. Legal requirements and professional standards were met. There was a good track record of safety and staff were proactive in learning lessons to improve their service.
• People who used the service had good outcomes because they received effective care and treatment that met their needs. Multi-disciplinary teams worked well together; there was a truly holistic approach to assessing, planning and delivering care and treatment. Staff were competent to deliver effective care in line with best practice guidance and professional standards.

• Staff ensured patients and those close to them were truly respected and valued as individuals. Where possible, people were empowered to be partners in their care both practically and emotionally. There was a strong, visible person-centred culture and staff were highly motivated and inspired to offer care that was kind and promoted patients’ dignity. Staff went the extra mile to ensure patients received care and support that exceeded expectations.

• Staff tailored services to meet the needs of individual people and delivered them in a way that ensured flexibility and continuity of care. Patient’s individual needs were central to the delivery and coordination of tailored services. There were innovative approaches to providing integrated person-centred care and to ensure that critical care services were more accessible for all patients that required it. Staff went above and beyond to ensure patients’ needs and preferences were met, and to enable patients to remain independent.
• The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. Leaders demonstrated high levels of experience, capacity and capability to deliver excellent and sustainable care. They had a deep understanding of issues, challenges and priorities in their service.

• There were high levels of satisfaction across all staff, including those with protected characteristics under the Equality Act. Staff were proud of the service as a place to work and spoke highly of the culture. Team-working and support across the service was exemplary, all staff had a common focus on improving the quality and sustainability of care and patients’ experiences.

Updated 31 October 2017

• End of life care at Sandwell Hospital was organised and delivered by a specialist palliative and end of life care service based at the hospital within the palliative care suite.

• There was a holistic approach to patient care and care was tailored to meet patient’s individual specific needs. The service regularly reviewed the complex care needs of patients to promote coordinated, safe, and effective palliative and end of life care. Patients and their families were extremely happy with the services provided to them and thought the care they received was ‘wonderful’. Patients and relatives told us that staff went that extra mile to not only meet their needs but to exceed them.

• The service provided access to care and treatment 24 hours a day, seven days a week. There is one single point of access for patients and health professionals (the Hub) to facilitate services that provide excellent coordinated care for patients and their families.

Updated 31 October 2017

• The trust followed the National Institute for Health and Care Excellence (NICE) clinical guidelines.

• Staff knew how to report incidents and told us that they received feedback. An IR(ME)R committee monitored, analysed and reported incidents in the diagnostic imaging department.

• All IR(ME)R documentation was in place.

• The diagnostic imaging department provided a seven-day service for patients requiring x-ray, computed tomography scans and interventional radiology.

• Staff in the outpatients department held additional clinics to reduce waiting times.

• The trusts follow up to new rate was one of the best in England.

• There were pathways and procedures in place for urgent referrals to the diagnostic imaging department.

• We saw that staff adhered to infection control policies and that there were robust processes in place for the cleaning of probes in the diagnostic imaging department.

• Staff in diagnostic imaging used the pause and check protocol. This ensured the patient, the examination and the referral were correct.

• We saw that staff were polite, caring, professional and compassionate towards patients.

• Staff fully explained procedures to patients; they gave patients time to ask questions and talked to patients in a way they could understand.

However:

• Resuscitation trolleys were unlocked and did not have tamperproof tags. Staff did not always record daily resuscitation trolley checks. Syringes of adrenaline and intravenous fluid bags were not stored appropriately.

• Staff in the outpatients department weighed patients in the corridor; this could lead to some patients feeling embarrassed as other patients and staff may have overseen.

• Staff did not keep patient notes secure in the outpatients department; this meant they were vulnerable to unauthorised access.

• Children had blood tests in the hospitals main phlebotomy department; we visited the department and found it was not child friendly.

• There had been a workforce review of staffing and this had led to significant changes at the trust, we saw pockets of low staff morale in the outpatients department caused by such changes.

• Staff in the outpatients department did not have their competencies assessed to ensure they were confident and competent to carry out their role.

• We were not assured that prescriptions for controlled drugs (FP10s) were being stored securely in outpatient areas in accordance with trust policy.

• Some staff had a limited understanding of the Mental Capacity Act, 2005.

Updated 31 October 2017

• We found that despite of some specific issues within theatres, infection prevention and control practices were good.
• Medicines were secured and staff access was auditable.
• Overall incident reporting and awareness was good.
• Nursing and medical staff levels were good and staff had the skills and knowledge relative to their role.
• Engagement with national clinical audit was good with evidence of learning from audit outcomes.
• Patients received appropriate care following nationally recognised pathways including control of pain.
• Multi-disciplinary team (MDT) working was evident throughout the service
• Patients told us that they received compassionate care, were involved in decisions about their care and supported when they were anxious or worried about their condition.
• Patients with special needs received appropriate support; staff understood how to support patients with dementia or other memory problems.
• Supervisors had a good understanding of their staff, were supportive, and provided an environment, which enabled staff to provide good care. We saw examples of innovative practice from individual members of staff, which had been adopted into practice across the trust.

However

• The trusts policy of pooling surgical patients had the potential to cause harm. Pooling of patients was a system where surgery patients were grouped by speciality and would be operated on by whichever surgeon was on duty for that speciality on the day of surgery, rather than by the consultant who had reviewed their case and recommended the procedure.
• Patient records contained errors and omissions.
• We saw some surfaces in theatres were cracked or had the wipe clean surfaces chipped or damaged which had not been repaired since the previous inspection in 2014.
• One member of the supervisory staff in theatres had a poor understanding of what constituted a serious incident, which meant we could not be assured incidents were always classified appropriately.

Updated 5 April 2019

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

• The service did not have enough nursing or medical staff with the right qualifications, skills, training and experience to provide the right care and treatment.
• The service did not have suitable premises to delivery consistently safe care to patients.
• The service did not store medication safely.
• The service did not consistently provide care and treatment based on national guidance or routinely update policies and procedures in line with current best practice.
• The service monitored the effectiveness of care and treatment; however, did not always use the findings to improve them in a timely manner.
• The service did not make sure staff were competent for their roles. Managers did not consistently appraise staff’s work performance.
• Staff did not always understand their roles and responsibilities in relation to 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 capacity to make decisions about their care.
• Staff did not consistently treat patients with compassion, kindness and dignity.
• The services Friends and Family Test results were on average 14% lower than the national average (March to August 2018).
• The trust did not plan and provide services in a way that met the needs of local people.
• Waiting times from treatment and arrangements to admit, treat and discharge patients were not in line with good practice.
• Managers across the trust did not promote a culture that supported and valued staff.
• The trust did not use a systematic approach to continually improve the quality of its services and safeguard high standards of care by creating an environment in which excellence in clinical care would flourish.
• The trust did not have effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

However:

• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately.
• The service assessed patients pain and prescribed and administered pain relief to patients.
• Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide care.
• Staff involved patients and those close to them in decisions about their care.
• The service treated concerns and complaints seriously, investigating them and learned lessons from the results, which were shared with all staff.