City Hospital

Updated 15 July 2021

We carried out this unannounced focused inspection because we had concerns about the quality of maternity services.

We did not inspect all core services rated as requires improvement at this trust because the services had not had time to make the improvements necessary to meet legal requirements as set out in the action plan the trust sent us after the last inspection. We are monitoring the progress of improvements to services and will re-inspect them as appropriate.

See the maternity section for what we found:

• Staff had training in key skills, understood how to protect women from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to women, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• Managers monitored the effectiveness of the service and made sure staff were competent. Midwives and consultants worked well together for the benefit of women.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. They were focused on the needs of women receiving care. Staff were clear about their roles and accountabilities. The service engaged well with women and the community to plan and manage services and all staff were committed to improving services continually.

However:

• The service did not have enough staff to care for women and keep them safe.
• Not all midwifery staff felt respected, supported or valued by the senior leadership team.

How we carried out the inspection

We were concerned about maternity services at the trust following recent concerns raised by patients and whistle-blowers, which we received between July and September 2020, and information we received from the trust. Therefore, we carried out an unannounced focused maternity inspection at City Hospital on 5 and 6 May 2021.

We inspected clinical areas in the service, including the delivery suite, antenatal and postnatal wards, the antenatal clinic, the maternity day assessment unit and community services. We spoke with 32 staff, including service leads, midwives, community midwives, medical staff, and student midwives. We reviewed six sets of patient records and six prescription charts and observed staff providing care and treatment to women.

Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activities. As we carried out a focused inspection related to the concerns raised, this did not include all our key lines of enquiry. As a result of this inspection, we rated safe and well-led as good, and the other key questions remained the same as per our previous inspection.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Updated 19 June 2020

We carried out an unannounced focused inspection of ward D26 (female elderly care) at City Hospital on 17 September 2019, in response to concerning information we had received in relation to pressure ar eas care of patients on this ward. We did not inspect any other core services , or any other locations provided by Sandwell and West Birmingham Hospitals NHS Trust.

We did not cover all key questions or key lines of enquiry and we did not rate this service at this inspection. We inspected elements of safe and effective.

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.

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.

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.

Updated 15 July 2021

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.

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.

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.