Archived: Birmingham Women's NHS Foundation Trust

Birmingham Women’s Hospital provides a range of health care services to women and families across the West Midlands and the UK which include gynaecology, maternity and neonatal care, as well as a comprehensive genetics service. On average, the trust looks after 50,000 patients a year and carries out over 3,000 operations. The trust also supports home births to women in South Birmingham.

The trust employs around 1,582 staff, 119 medical, 550 nursing and 913 staff are from other disciples including non-clinical and administrative staff. The hospital has 210 beds, 117 provided for maternity inpatient services, 53 for neonatal intensive care, this includes transitional care ward, intensive care unit, high dependency unit, special care baby unit and 42 for gynaecology services.

We carried out an announced inspection visit from 12 to 14 April 2016 and three unannounced visits on 15, 25 and 27 April 2016. This inspection was part of our comprehensive inspection programme.

We held focus groups with a range of staff in the hospital, including consultants, midwives, nurses, junior doctors, student midwives and nurses, administrative and clerical staff, pharmacists, domestic staff and porters. We also spoke with staff individually.

We inspected and reported the Termination of Pregnancy services (ToPS) under Surgery and Gynaecology services because the volume of ToPS activity did not warrant an individual report. For the same reason, aspects of end of life care for women and babies was inspected and reported under Surgery and Gynaecology and neonatal services.

Overall, we rated this trust as requires improvement. We found that safety and caring was good and effective, responsive and well led required improvement.

The senior team were visible and accessible to staff, and managers were seen as supportive and approachable. Managers were keen to engage and include staff in service development. There were concerns raised in relation to the Termination of Pregnancy service and care pathways in OPD and diagnostic services, however the trust had commissioned an external review to look at issues raised.

There was a positive and enthusiastic culture throughout the hospital. Staff were committed and passionate about their work and proud of the services they offered to patients. Staff were keen to learn and continuously improve and patients were generally very positive about the care and treatment they received at the hospital.

We did not inspect genetics, pathology or fertility services as we have no regulatory remit to do so.

Our key findings were as follows:

Safe

• In surgery and gynaecology services we observed several occasions where infection control practices were not followed. For example, a member of staff assisted a patient with their wound drain and catheter and then proceeded to serve patients at lunch without cleansing their hands. A patient had been moved to a side room with an infectious condition, we observed a member of staff leaving the room and did not sanitise their hands and went on to make tea for patients.

• Not all staff complied with the “bare below the elbows” policy. We saw two staff serving food, who were wearing jewellery such as a watch, a large ring (with stone) and large looped earrings.

• There were no reports of Methicillin-resistant Staphylococcus aureus (MRSA) Methicillin-sensitive Staphylococcus aureus (MSSA) or Clostridium difficile reported between December 2014 and December 2015 trust wide. Patients received care in a visibly clean and suitably maintained environment.

• There was a high standard of cleanliness throughout most services. The large majority of staff were aware of current infection prevention and control guidelines. They were supported by staff training and the adequate provision of facilities and equipment to manage infection risks.

• Maternity inpatient service met the national benchmark for midwifery staffing as set out in the Royal College of Obstetricians and Gynaecologists guidance (Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour) with a ratio of one midwife per 28 patients. There were sufficient nursing staffing levels across surgery and gynaecology.

• Neonatal staffing levels did not meet the British Association of Perinatal Medicine (BAPM) standards of nurse to patient ratio. However, neonatal staff worked extra hours to fill gaps on the staffing rota which ensured care and treatment was delivered in a timely manner.

• There were challenges to fill sonography vacancies in the outpatient department which resulted in long waiting times.

• There were sufficient numbers of consultants to provide good quality care and treatment for patients in line with Royal College for Obstetricians and Gynaecologists guidance.

• From January 2014 to June 2015 maternity inpatients showed there was 90-120 hours coverage per week which was below the Royal College for Obstetricians and Gynaecologists (RCOG) recommendations of 168 hours for the number of births.

• BWH offered specialist services to women with often complex medical conditions. The Trust had reported five maternal deaths in the last 26 months. An external review had been commissioned and was underway to review the trusts investigations into each death in order to identify any common themes or patterns. We reviwed the external report and saw there were no common themes for the five cases.

• A perinatal and maternal mortality and morbidity meeting was held monthly, this involved multidisciplinary team members (MDT), Minutes and lessons learnt were shared widely across the service.

Effective

• We noted the information on medical terminations of pregnancy did not include the risk of a late gestation foetus showing ‘signs of life’ and the potential requirement to register with the coroner.

• Several nurses across ToPs expressed concerns to us as they had not received training that would equip them to deal with the physical and emotional aspects of advanced gestation abortions.

• In addition within ToPS two incidents (trust data showed five for Quarter four in 2015/16]) reported on the trust’s incident reporting system, there were other occasions when the condition of the foetus had given them cause for concern and the action they should have taken was unclear.

• Within ToPS we saw the root cause analysis of an incident that led to a serious case review underway at the time of our inspection indicated teamwork between the abortion care service, ward team and bereavement team and wider medical team needed to be strengthened as sharing of information in and out of the service between the MDT was inconsistent.

• Patients reported unnecessarily lengthy periods when they were unable to eat and drink prior to undergoing surgery and we found there were variations in the instructions about this for patients, depending on the anaesthetist involved. The trust had been unable to reach a consensus in order to achieve a consistent approach and reduce the amount of time patients were unable to eat and drink to a minimum.

• Policies were based on national guidance produced by NICE and the Royal Colleges. Staff had access to guidance, policies and procedures via the trust intranet.

• Care and treatment were delivered throughout the trust in accordance with evidence-based guidelines. The trust had a system for receiving, recording, assessing and monitoring compliance with NICE guidance. Quarterly reports were provided for commissioners as part of the quality contract requirements.

• Patients’ religious and cultural needs were considered and food was provided in accordance with their requirements. Staff gave appropriate and discreet support to those patients who needed help with eating and drinking. Specialist dietary support was available to patients whose condition indicated or required a specialist diet.

• Parents were supported in their chosen method of feeding. When mothers chose to breast feed but were unable to due to the baby’s condition, facilities were provided for expressing breast milk in private.

Caring

• We saw excellent care provided across the trust in many areas, particularly in inpatient maternity where the care was outstanding.

• We observed caring and compassionate interactions between staff and women, when new mothers felt they needed to talk or they felt anxious staff would speak with them even in the middle of night and looked after their baby overnight so the mother could catch up on their sleep.

• Excessive waiting times in antenatal clinics in some cases was more than five hours and some women were told to attend the hospital twice in one day with split appointments for bloods and a scan.

• Patients with pregnancy loss or termination of pregnancy did not have the same range of options for disposal of remains as other patients/families. The bereavement and spiritual care service stated its intention to improve this.

• Although there was access to translation services for people for whom English was not their first language, some staff within surgery services perceived the use of family members to interpret for patients to be the first option.

• There was a specialist midwifery team for vulnerable women which comprised of a specialist midwife in perinatal mental health, substance and alcohol misuse, teenage pregnancy, female genital mutilation, smoking cessation and high risk pregnancy.

• Women with a learning disability were supported through an integrated acute and community approach.

• Patients’ religious and cultural needs were met through a multi-faith chaplaincy and a bereavement service for parents and those close to them who had lost their babies.

• Six parent flats were available close to the neonatal intensive care unit (NICU) for families to stay near to their baby.

Responsive

• We noted the information on medical terminations of pregnancy did not include the risk of a late gestation foetus showing ‘signs of life’ and the potential requirement to register with the coroner.

• Bed occupancy for 2014/2015 was between 64% and 72%, however for 2015/2016 the bed occupancy ranged between 72% and 82% and both years were higher than the national average.

• Within neonatal services bed capacity leads worked six days a week to organise patient transfers and admissions. The unit did not close to patients in need of admission however, at times the unit would delay ex-utero (babies already born) transfers until cots were vacant and staffing levels were appropriate.

• One couple in the antenatal clinic who complained about waiting for more than five hours on their last visit to have their blood tests, scan and doctor’s appointment. They waited on the day of our inspection for the triage appointment for three hours and then waited a further two hours to see a doctor.

• One patient explained they had a blood test carried out in the morning and were told to return for a scan in the afternoon.

Well led

• An independent review of the trusts’ governance arrangements by an independent nationally respected organisation was carried out in March 2016, prior to its planned acquisition by Birmingham Children’s Hospital. The findings of this review and our findings were similar.

• Risk management across directorates was variable, governance and risk management structure across maternity inpatient maternity community, surgery and gynaecology and neonatal services was well embedded.

• The board were largely aware of the current status of the effectiveness of governance arrangements at the trust and were aware of the need for further development across its services.

• We found the (BAF) which forms part of the NHS England risk management strategy and is the for identification and management of strategic risks required further development. Three key risks were identified; staffing, finance and flow, linked specifically to the antenatal pathway. We were not assured that the BAF was clear who had responsibility and that risks were fully identified, understood and managed appropriately.

• There were challenges around governance arrangements and risk management with termination of pregnancy service. For example, the new contract for the termination of pregnancy service had commenced in January 2015. At the time of the inspection training for staff had not been formalised despite concerns expressed by staff about the need for clarity regarding actions to be taken.

We saw several areas of outstanding practice including:

• The symptom specific triage assessment card within inpatient maternity services delivered consistency and clear targets for the triage process.

• Video books were available for women across acute and community services who did not speak or read English.

• The trust was awarded a (SDIP) grant by local commissioners to pilot a three year project to set up a Homebirth Service, one of its kind in the region.

• Funding was sought from the Local Education Training Council (LETC) to fund a two year foundation degree to enable the maternity assistants to acquire the necessary competencies to assist the midwife at home-births.

• Staff within the neonatal services introduced the routine use of pulse oximetry for all babies within 24 hours of birth or prior to discharge. This has been identified as significant in the early detection of critical congenital heart defects prior to the deterioration of the baby. The business case and rationale for testing has been shared nationally and around 20% of hospitals now routinely perform this test.

• Gynaecology services had been successful in becoming an accredited British gynaecology endoscopy (BSGE) centre for complex endometriosis. This is a regional specialist service whereby women with complex endometriosis are referred and includes medical, pain related and surgical management.

• The Trust as a whole achieved Baby Friendly status in April 2013. A new approach and standards have been developed by UNICEF and Maternity service has been reaccredited under the new standards.

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

Importantly, the trust must:

Actions the trust MUST take to improve;

• Healthy Start vitamins must be stored securely in all community maternity team offices.

• Medicines prescribed and stored in line with the trust policy, particularly intravenous fluids.

• All community midwives must attend safeguarding supervision in line with Department of Health requirements (Working Together to Safeguard Children, 2015).

• Improve the application of infection prevention and control procedures in relation to the use of personal protective clothing and equipment and hand hygiene.

• Properly maintain all equipment and medical devices.

• Provide secure storage for patient records across all clinical areas.

• Ensure the project to develop a second emergency theatre team is progressed in a timely manner.

• The trust must ensure all HSA1 certificates for termination of pregnancy are fully completed by the registered medical practitioners signing them.

• Identify, monitor and mitigate all risks relating to developing the complex abortion service pathway. In particular in respect of processes required and the impact on staff and patients of distressing elements of late gestation termination.

• Provide training to ward staff caring for complex abortion services patients in the appropriate procedures for responding to late gestation termination of pregnancy where the foetus may be indicating signs of life.

• Ensure team work between the complex abortion care service, ward teams and bereavement team and wider medical teams are strengthened to mitigate risks involved in late gestation termination of pregnancy.

• Take steps to ensure multi-disciplinary team work is improved where clinicians from other trusts are contributing the care of patients.

• Clarify the method clinician’s should use to establish consent to termination of pregnancy from adult patients with learning disabilities.

• Ensure that the data collected for the Neonatal Audit Programme (NNAP) reflects the care given within the unit.

• Ensure staff receive mental capacity training in line with trust guidance.

• Implement a system to assess, monitor and improve the waiting times across clinics in the outpatients and diagnostic departments.

• Mitigate the risks relating to the health, safety and welfare of service users by regularly reviewing the risk register and include a timescale in completing any risks identified.

• Reduce the waiting times in diagnostics department by having sufficient numbers of qualified staff.

• Provide community maternity staff with secure facilities and guidance to retain old diaries.

Professor Sir Mike Richards

Chief Inspector of Hospitals