The Care Quality Commission
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Birmingham Women's and Children's NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Requires improvement read more about inspection ratings
Important: Services have been transferred to this provider from another provider

All Inspections

23 to 24 January 2024

During a routine inspection

The emergency department at Birmingham Children’s Hospital provides a 24-hour, 7 day a week service to children and young people in the local area and beyond. The service is a member of a regional trauma network and a designated trauma unit for children and young people. The department can provide care for a wide range of medical conditions, minor illnesses, and injuries through to major trauma.

From March 2021 to February 2022, the emergency department saw over 62,957 children and young people. Children, young people and their parents/carers were referred by 999 calls, their GPs or attended ‘self-referring’ walking into the reception area. There were 5 beds and a cubicle in the observation area, 10 cubicles, 3 resuscitation beds, 19 bedded paediatric assessment unit and the clinical decision unit had 11 beds for GP, specialty referrals and for accommodating patients waiting for admission. The minor injury area consisted of a treatment room, 5 bed spaces and a seating area.

We inspected the service on the 23 and 24 January 2024. The inspection team comprised an operations manager, 2 inspectors, 3 specialist advisors which included a consultant in paediatric emergency medicine, a modern matron and a Child and Adolescent Mental Health Service specialist advisor. An operations manager oversaw the inspection.

During our inspection, we visited all areas within the children’s emergency department including paediatric assessment unit.

Throughout our inspection we spoke with 34 staff including doctors, nursing staff of various grades, healthcare support workers, advanced nurse practitioners and managers.

We reviewed a total of 26 patient records and spoke with 12 children, young people and their relatives.

You can find further information about how we carry out our inspections on our website.

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

  • The service provided mandatory training in key skills but not all staff completed it. The service did not provide training to care for patients with complex needs. Not all relevant staff were trained to the appropriate level of life support training. The service did not always control infection risk well. Staff did not always use control measures to protect patients from infection. The design and use of facilities and premises did not always keep people safe. There was limited provision for specialist mental health assessment for patients presenting with acute mental health needs. Controlled drug recording did not always follow the Misuse of Drugs regulations 2001. Learning from serious incidents was not always embedded to improve patient safety.
  • Not all staff knew how to protect the rights of patients subject to the Mental Health Act 1983. Not all staff understood their responsibilities in managing patients experiencing mental ill health. The service did not always monitor the effectiveness of care and treatment. Not all staff had received training in consent, Mental Capacity Act and Deprivation of Liberty safeguards.
  • The service was inclusive but did not always take account of patients’ individual needs and preferences. People did not always receive the right care promptly.
  • The service did not always collect reliable data to enable them to analyse it to inform performance monitoring and future improvements. Information systems were not all integrated. Implementation of quality and safety improvements was not always timely. Arrangements were in place with partners and third-party providers, but these were not always effective.

However:

  • Staff-maintained equipment well and were trained to use it. Staff quickly acted on patients at risk of deterioration. Managers regularly reviewed staffing levels and skill mix, and gave bank staff a full induction. Staff kept detailed records of patients’ care and treatment. Records were clear, up to date, stored securely and easily available to all staff providing care. The service managed patient safety incidents well.
  • The service provided care and treatment based on national guidance and evidence-based practice. Staff gave patients enough food and drink to meet their needs. Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way. The service made sure staff were competent for their roles. Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. Key services were available 7 days a week to support timely patient care. Staff gave patients practical support and advice to lead healthier lives.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned and provided care in a way that met the needs of local people. People could generally access the service when they needed it. It was easy for people to give feedback and raise concerns about care received.
  • Leaders had the skills and abilities to run the service. They were visible and approachable. The service had a vision for what it wanted to achieve and a strategy to turn it into action. Staff felt respected, supported and valued. Leaders and staff actively and openly engaged with patients, staff and equality groups. They collaborated with partner organisations to help improve services for patients.

22 August 2023, 23 August 2023

During an inspection of Specialist community mental health services for children and young people

We carried out this short time announced focused inspection because at our previous inspection we rated the mental health services at the trust overall as Inadequate. We rated Safe, Responsive and Well-led as Inadequate and Effective and Caring as Requires Improvement.

At our previous inspection we rated this core service of Specialist Community Mental Health Services for Children and Young People as Inadequate overall; we rated Safe, Responsive, and Well-led as Inadequate and Effective and Caring as Requires improvement.

Birmingham Women's and Children's NHS Foundation Trust is responsible for managing Forward-Thinking Birmingham. The Trust was created following a merger of Birmingham Women's NHS Foundation Trust with Birmingham Children's Hospital NHS Foundation Trust in February 2017. The trust is one of five trusts within the Birmingham and Solihull Integrated Care System (ICS).

Forward Thinking Birmingham is registered by the Care Quality Commission (CQC) to provide the following regulated activities: Assessment or medical treatment for persons detained under the Mental Health Act 1983, Diagnostic and screening procedures and Treatment of disease, disorder or injury.

Forward Thinking Birmingham is one of the largest Child and Adolescent Mental Health Services in England. It has a dedicated inpatient eating disorder and acute assessment unit for regional referrals of children and young people with the most serious mental health concerns s (Tier 4) and provides community mental health service for 0–25-year-olds.

This was a core service inspection of the specialist community mental health services for children and young people at the Parkview clinic location. We visited all the sites where this core service operated from:

South Hub, Oaklands Centre Raddlebarn Road, Selly Oak Birmingham

East Hub, Blakesley Centre, 102 Blakesley Road, Yardley, Birmingham

North Hub, Finch Road, 2 Finch Road, Lozells Birmingham

West Hub, Finch Road, 2 Finch Road, Lozells Birmingham

At this inspection our rating of this core service ​improved​. We rated them as ​requires improvement​ because:

  • Although there had been improvements in how staff assessed and managed the individual risks of children and young people, managers did not always take timely action to ensure clinical premises where people were seen were safe and well maintained. Clinical premises were not maintained and monitored in a way that mitigated all identified risks.

  • The trust had taken some action since the previous inspection to ensure premises were fit for purpose. However, staff raised concerns about disabled access to the sites, inability to control temperature, child and adults shared facilities, lack of clinical space, and some necessary equipment was obsolete. Following this inspection, the trust told us of the plans to move the East Hub early in 2024 to a more suitable location. The trust was aware of the environmental risks and this was reflected in the trust’s estate strategy. Providing alterative accommodation is dependent on capital funding and regional approval processes which we will monitor through our engagement with the trust. All environmental concerns identified on the audits were included as open risks on the trust risk register and monitored through the trust’s non – clinical risk committee.

  • Children and young people’s privacy and dignity were not always protected and promoted. Not all interview rooms in the service had sound proofing to protect privacy and confidentiality.

  • The teams did not include or have access to the full range of specialists required to meet the needs of the patients. There were nursing, multidisciplinary team and consultant vacancies. These vacancies had an impact on the internal waiting lists for allocation of these specialists.

  • Managers had not ensured that all staff had accessed supervision, and appraisal.

  • Staff with more limited experience supported patients and were included in the duty cover system. However, they were supported by a lead clinician who was accountable for the clinical caseloads and the duty cover system.

  • Although there had been a recent reduction in some waiting lists, the service was not always easy to access. Some children and young people were waiting over 18 weeks to access services or interventions that they needed.

  • Our findings from the other key questions demonstrated that governance processes did not always operate effectively at team and trust level to ensure that performance and risk was well managed.

  • Mental Health Act and Mental Capacity Act training were combined. At this inspection overall only 73% of staff had received training for Mental Health Act and Mental Capacity Act and at East Hub this was lower at 66%.

  • The service had not acted on feedback from children and young people about the environment at the East Hub including the waiting area, hallways and entrance, and therapy rooms.

However:

  • Managers and staff had made some improvements to the service following our previous inspection. We saw improvement in how staff assessed and managed individual risk concerns, identified, managed and shared learning from risk incidents, and in multidisciplinary and multiagency working, including safeguarding.

  • The trust used systems to help them monitor waiting lists and staff assessed and treated patients who required urgent care promptly. The criteria for referral to the service did not exclude children and young people who would have benefitted from care. Managers monitored caseloads and had improved processes to ensure people were not ‘lost to follow up’ and that staff contacted children and young people who did not attend appointments.

  • Staff worked well together as a multidisciplinary team and with relevant services outside the trust. Staff assessed and managed risk well and followed good practice with respect to safeguarding. Specialist safeguarding nurses offered enhanced support across sites.

  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.

  • Staff understood the principles underpinning capacity, competence and consent as they apply to children and young people and managed and recorded decisions relating to these well.

  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.

  • A family therapist at South Hub told us they involved an expert by experience in groups to assist with therapeutic support. (An expert by experience is a person who has personal experience of using services).

  • We observed compassionate, kind, and caring interactions between staff, children and young people’s families and carers.

What people who use the service say

We spoke with 13 children and young people and received mixed feedback about the service.

One person said their care coordinator kept changing. Some people told us some staff were rude. One person said some staff were not helpful. Another person said there was a lack of communication.

Three people said staff did not always signpost them to other groups and services. They picked up leaflets about support groups in Hub reception areas, but the staff did not know anything about the group.

Four people said when leaving a telephone message for staff, they did not always respond quickly.

One person said they liked the staff; they are all very good. None of their appointments had been cancelled, but if they had to rebook, it was no problem.

We received feedback about medicines management. 12 of the 13 people spoken with were positive about the management of their medicines. However, one person said they had fortnightly prescriptions which were never ready. They had to ring to order and ring to ask when ready and when they arrived to pick up it wasn’t ready. One person said there had been problems with repeat prescriptions, but this had improved.

We spoke with people about the environment of the hubs they visited for their appointments. One person said the trust needed to brighten up the reception area at East Hub Blakesley Centre, as it made them feel depressed and worse.

Another person said, "The service helped me to get a job. If you asked me a year ago if I would be working, I would have said, no way. I am grateful."

21, 22, 23 June 2022, 25 and 26 July 2022, 9 and 10 August 2022, 10 and 11 October 2022.

During a routine inspection

Birmingham Women's and Children's NHS Foundation Trust is responsible for managing Birmingham Women's Hospital, Birmingham Children's Hospital and Forward Thinking Birmingham. It was created by a merger of Birmingham Women's NHS Foundation Trust with Birmingham Children's Hospital NHS Foundation Trust in February 2017.

The trust is one of five trusts within the Birmingham and Solihull Integrated Care System. It has an annual turnover of £535 million, and provides a range of general and specialised services, including tier 4 Children’s and Young Persons mental health services to young people up to the age of 25 years.

Birmingham Women’s Hospital provides specialist services to more than 50,000 women, men and their families every year from the city, the wider region and beyond. One of two dedicated women’s hospitals in the UK, the maternity unit delivering more than 8,200 babies a year. The hospital offers a full range of gynaecological, maternity and neonatal care. The fetal medicine centre receives regional and national referrals and is home to the West Midlands Regional Genetics Laboratory.

Birmingham Children’s Hospital is a specialist paediatric centre, caring for sick children and young people up to the age of 16. The hospital has a national liver and small bowel transplant centre. They are a nationally designated specialist centre for epilepsy surgery and host a paediatric major trauma centre for the West Midlands. Alongside a Paediatric Intensive Care Unit.

Forward Thinking Birmingham is one of the largest Child and Adolescent Mental Health Services in England, with a dedicated inpatient eating disorder unit and acute assessment unit for regional referrals of children and young people with the most serious of problems (Tier 4), and the Forward Thinking Birmingham community mental health service for 0-25 year olds.

Between 21 June 2022 and 11 October 2022, we carried out an unannounced inspection of two of the acute and the three mental health services provided by this trust as part of our continual checks on the safety and quality of healthcare services. We also inspected the well-led key question for the trust overall.

We inspected critical care and surgery at Birmingham Children’s Hospital and specialist community mental health services for children and young people, child and adolescent mental health wards and mental health crisis services and health-based places of safety; all part of Forward Thinking Birmingham. We inspected these services as our intelligence suggested there may have been a deterioration in the safety and quality of care provided.

Following this inspection, due to concerns found within the specialist community mental health services and on the child and adolescent mental health wards, we issued the trust with a Letter of Intent to take urgent enforcement action if significant improvement was not made. The trust took action and we received initial assurances that improvements were being made. We revisited the services between 10 and 11 October 2022 and found that significant improvement was still required in the quality of healthcare relating to management of risk due to issues with records.

We did not inspect any other services at Birmingham Children’s Hospital or Birmingham Women’s Hospital because our monitoring process had not highlighted any concerns. We will re-inspect these services as appropriate.

NHS England System Oversight Framework provides the framework for overseeing systems including providers and identifying potential support needs. The framework looks at five national themes: quality of care, access and outcomes, preventing ill health and reducing inequalities, finance and use of resources, people and leadership and capability.

Based on information from these themes, providers are segmented from 1 to 4, where ‘4’ reflects providers receiving the most support, and ‘1’ reflects providers with maximum autonomy. As of April 2022, the trust’s segmentation was 2.

Our comprehensive inspections of NHS trusts have shown a strong link between the quality of overall management of a trust and the quality of its services. For that reason, we look at the quality of leadership at every level. Our findings are in the section headed ‘is this organisation well-led’. We inspected the well-led key question between 9 and 10 August 2022. A financial governance review was also carried out at the same time as the well-led inspection, this was undertaken by NHS England. There was not a separate ‘Use of Resources’ assessment in advance of this inspection.

Our rating of services went down. We rated them as requires improvement because:

  • We rated, safe, responsive and well-led as requires improvement and effective and caring as good.
  • In rating the trust, we took into account the current ratings of services not inspected this time.
  • Services that formed part of Forward-Thinking Birmingham (FTB) did not always provide safe care. FTB services did not always have enough nursing staff and support staff to keep patients safe.
  • In the acute surgery services, staff did not always ensure that risks associated with the environment and equipment were consistently mitigated. Care records were not always stored securely ensuring personal and sensitive information was protected. The service did not always ensure safe systems were followed to prescribe, administer and store medicines. Children, young people and their families' individual care preferences were not always recorded to show these had been assessed and responded to.
  • In acute and FTB services, action was not always taken to ensure risk assessments and risk management plans were consistently recorded for all relevant aspects of care and treatment. When risk assessments and management plans were in place, they were not always updated in response to changes to children and young people’s care needs.
  • Not all staff in FTB services worked well together for the benefit of patients. Staff did not always work well with the psychiatric liaison team, who often referred adults to the crisis service.
  • Staff in FTB services did not always understand the individual needs of children and young people who used the service. They did not always actively involve children, young people and their families in care decisions.
  • In specialist community mental health services for children and young people, children and young people sometimes had to wait long periods of time for their treatment.
  • The FTB service was not well led, governance processes did not ensure that procedures relating to the work of the service ran smoothly.
  • In FTB services, staff could not always find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements.

However:

  • The acute services had enough staff to care for patients and keep them safe. Most staff had training in key skills, understood how to protect patients from abuse, and managed safety well. Services controlled infection risk well. Staff in the paediatric intensive care unit (PICU) assessed risks to patients, acted on them and kept good care records. PICU staff managed medicines well. Services managed safety incidents well and learned lessons from them.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers mostly monitored the effectiveness of services and made sure staff were competent. Most staff worked well together for the benefit of patients, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff in the acute services treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • Most services planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed.
  • Leaders ran acute 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. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. Services engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.
  • The trust collected reliable data and analysed it. In acute services, staff could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. The information systems were integrated and secure. Data or notifications were consistently submitted to external organisations as required.

How we carried out the inspection

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

What people who use mental health services say

Children and young people who used the mental health services told us they did not have a care plan and information about their treatment was not explained to them.

Children and young people said there were not enough staff and the staff member supporting them often changed. They said their appointments were cancelled due to staffing or they did not run to time. Children and young people said face to face appointments were not offered freely even if it is a preference.

Children and young people said access into the service needed to improve as they waited too long which often resulted in them reaching a crisis point. One person said they only received help after they had been in crisis and went to the local emergency department. People said they waited a long time to see the doctor.

Children and young people said they did not receive feedback about complaints they had made, other people did not know how to make a complaint and some people did not feel listened to.

However:

A relative said they and their family felt listened to and were involved.

Some children and young people said staff were responsive and answered any questions they had, were lovely, polite and respectful. People said the care coordinators were consistently great. They told us that they had waited a long time but once they received the care it was very good, and they would be lost without the support they received.

Children and young people said the service was passionate about patient voice and co-production.

They said there was effective signposting to other services and charities and therapy and counselling sessions were very helpful.

2 Apr to 25 Apr 2019

During a routine inspection

Our rating of the trust went down. We rated it as good because:

  • Forward Thinking Birmingham was rated as requires improvement overall. Of the core services inspected in April, one core service was rated requires improvement overall and two core services were rated as good overall.
  • Birmingham Women’s Hospital was rated as good overall. Of the core services inspected in April, one core service was rated requires improvement overall and four core services were rated as good overall.
  • Birmingham Children’s Hospital was rated as outstanding overall, Surgery was inspected in April and caring was rated as outstanding.

Our full inspection report summarising what we found and the supporting evidence appendix containing detailed evidence and data about the trust is available on our website – www.cqc.org.uk/provider/RQ3/reports.

2 Apr to 25 Apr 2019

During an inspection of Mental health crisis services and health-based places of safety

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

  • The service provided safe care. Clinical premises where patients were seen were safe and clean and the physical environment of the health-based places of safety met the requirements of the Mental Health Act Code of Practice. The number of patients on the caseload of the mental health crisis teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff managed waiting lists well to ensure that patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
  • Staff working for the mental health crisis teams developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The mental health crisis teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff understood the principles underpinning capacity, competence and consent as they apply to children and young people and managed and recorded decisions relating to these well.
  • Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • The mental health crisis service and the health-based places of safety were easy to access. Staff assessed patients promptly. Those who required urgent care were taken onto the caseload of the crisis teams immediately. Staff and managers managed the caseloads of the mental health crisis teams well. The services did not exclude patients who would have benefitted from care.
  • The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

  • Staff did not always accurately record information in relation to the Mental Health Act in the health based place of safety. This meant staff could not be sure how long a patient had been detained.
  • We found some medication errors relating to the disposal of controlled drugs, signage for storage of oxygen cylinders and archived prescription charts which had not been stored correctly
  • In the health based place of safety, it was not possible for staff to know if a fire alarm had been activated in the suite as there was no fire panel in that area.

2 Apr to 25 Apr 2019

During an inspection of Specialist community mental health services for children and young people

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

  • The number of patients on the caseload of the teams, and of individual members of staff, was high. Staff told us this could prevent them from giving each patient the service they needed. There were not enough staff to deal with the increasing levels of referrals or the backlog of patients waiting to be seen.
  • Staff turnover was high across the service, staff expressed feeling overwhelmed and overstretched, and their morale was low.
  • The service was not easy to access in a timely manner. Most patients had to wait a long time to get the help they needed because there were high numbers of patients waiting to access the service. The service was not meeting referral to treatment targets.
  • Consultation rooms where patients met with staff were not effectively soundproofed in two out of the four community hubs. The rooms were too hot and there were not enough consultation rooms to accommodate the needs of the service.
  • Records did not consistently evidence that patients had been supported to address their physical health needs or had been offered a copy of their care plan.
  • The service was generally well led and had improved since our last inspection. The governance processes ensured that procedures relating to the work of the service had improved in most areas. Managers’ understanding of pressures on the service, and on staff delivering the service, had improved. Measures had been put in place to deal with the pressures but these needed to go further and become embedded before significant improvement would be seen. High staff vacancies had persisted for long periods and showed only recent improvement. Staff were not given the right tools and support to work to an agile model. High waiting lists dominated activity across the service and staff used words such as “firefighting” to describe the culture they had grown accustomed to working in.

However:

  • Staff assessed and treated patients who required urgent care by referring them to the urgent care team or offering an urgent choice appointment. The criteria for referral to the service did not exclude children and young people or young adults who would have benefitted from care.
  • The service provided safe care. Clinical premises where patients were seen were safe and clean. Staff managed waiting lists well to ensure that patients who required urgent care were seen promptly, even though this may be by the urgent care team. Managers had much improved the way they monitored the waiting lists of patients waiting to access support. Staff assessed and managed risk well and followed good practice with respect to safeguarding. Mandatory training compliance had improved across the service.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. The recording of patient records to reflect this had much improved. Staff provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. A number of bank and agency vacancies were filled by staff who had been in post a long time. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
  • Staff understood the principles underpinning capacity, competence and consent as they apply to children, young people and young adults. There had been improvements in the recording of capacity in patient records.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients, families and carers in care decisions.

26 - 27 July 2017

During an inspection of Specialist community mental health services for children and young people

We changed the overall rating from requires improvement to inadequate because:

  • Following the inspection in May 2016, we told the provider of the actions they must take in order to improve the service. During this inspection, we identified that the trust had only completed three of the eight actions we had told them they must complete.

  • Patients were at risk of harm because systems and processes were not in place to keep them safe. During inspection, we identified a number of concerns in relation to infection control, medicines management practice, health and safety, risk assessment, care planning, safeguarding, patient record keeping, staffing, governance and leadership.

  • Not all the environments were safe and clean. Staff did not always adhere to infection control principles, maintain clean environments or have systematic approach to deal with risks identified. Staff were not sure how to respond to an activated alarm call. Staff did not always adhere to the Control of Substances Hazardous to Health Regulations.

  • Medicine management was poor at the urgent care team base, South and East hubs. Staff did not store or dispose of medicines correctly. Staff did not routinely undertake medicines audits.

  • Not all patients had an up to date fully completed risk assessment or risk management plan. Where we saw risk assessments in place they were basic and lacked detailed information.

  • Not all patients had a care plan. Where we saw care plans in place, they were not personalised, specific or detailed. Some care plans did not address young peoples’ identified needs. Staff did not always record patients’ views. A clinical audit of care plans had not led to improvements in care record documentation.

  • Staff could not always access electronic care records in a timely manner. The lack of detail in electronic care records meant that even if staff could access records, the information was not always there. The high use of agency staff and turnover added to the unsafe hand over of care and inconsistent monitoring of patients. The lack of oversight from managers also meant that some patients were not reallocated care coordinators when staff left or passed between teams.

  • Although staff had access to mandatory training, staff compliance rate in some modules were low. These included adult safeguarding level 2 and children’s safeguarding level 3. National guidance from an intercollegiate document published by the Royal College of Paediatrics and Child Health set out minimum safeguarding children training requirements for NHS staff. All staff within a child and adolescent mental health service should be trained to level 2 minimum and all clinical staff who work directly with children and young people should be trained to a minimum level 3. Across the core service only 46.5 % of eligible staff had completed level 3 children’s safeguarding.

  • Overall governance within the integrated community services lacked coordination amongst partners and there were clear issues with data collection, monitoring of waiting lists, and allocation of caseloads, staffs understanding of standard operational policies and estates management. Data shared by the trust was at times contradictory and not always broken down between hubs and teams. The trust themselves had identified issues with data collection amongst staff and systems.

  • The core service had a overall staff vacancy rate of 27%. The trust employed a high number of agency staff to cover the majority of vacancies but44% of these vacancies had not been filled. This all impacted directly upon patient care resulting in poor patient handovers, cancellation of appointments, increasing waiting lists, patients waiting allocation of care coordinators, inconsistent care and low staff morale.

However:

  • The trust provided a health-based place of safety for patients under the age of 18.

  • The trust had updated the health-based place of safety policy in line with the revised Mental Health Act Code of Practice 2015.

  • Patient care records we reviewed from the health-based place of safety showed that staff assessed and documented risks and management plans.

  • Clinical staff we met were experienced and skilled and from a wide range of mental health disciplines.

  • Staff were able to provide psychological therapies recommended by the National Institute for Health and Care Excellence.

  • Staff had a good understanding of Gillick competence.

17-19 May 2016, Unannounced 26 May 2016

During a routine inspection

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.

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

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.

We rated the trust ‘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 move into adult services. Services were offered both in and out of the hospital, and the multidisciplinary team worked in a cohesive fashion such 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

17th-19th May 2016

During an inspection of Specialist community mental health services for children and young people

We rated the community mental health services for children and young people as requires improvement because:

  • There were shortfalls in the staffing establishment. At the time of our inspection, the community mental health services for children and young people had an overall vacancy rate of 26% and a staff turnover rate of 22%. This was on the trust risk register at the time of our inspection.

  • There were large waiting lists for young people requiring treatment for attention deficit hyperactivity disorder and who had been transferred to the care of Forward Thinking Birmingham as part of the reconfiguration of services. At the time of our inspection there were 441 young people awaiting their first appointment with services and staff raised concerns this number was increasing.

  • Young people were not transferred from the home treatment team to the care of the community hubs at the point they were ready. This was due to a lack of capacity and staff in the community hubs. This was on the trust risk register at the time of our inspection.

  • The learning disabilities service was not meeting trust key performance indicator targets for children and young people seen within 18 weeks from the point of referral

  • Staff within Birmingham Children's Hospital reported that they did not always feel they had been consulted with effectively during the roll out of the new approach to providing mental health services for young people: "Forward Thinking Birmingham".

  • Risk assessments were not always up to date. Reviews of risk were noted in clinical entries but the screening tool had not always been reviewed or updated.

  • The signatures of young people and their families and carers were not always found in care planning documentation. This meant that consent to treatment was not always accurately recorded.

  • The policy for the place of safety at Parkview Hospital did not reference the new and updated 2015 Mental Health Act Code of Practice. Staff at the place of safety had not made accurate records of the start and finish times of the use of the section 136 suite

  • Morale was variable across the community teams and team meetings were not taking place consistently. Learning from lessons was not always evident and staff reported they were working less collaboratively following the reconfiguration of services.

  • A combination of paper and electronic records meant that information was not always available or accessible for staff. The trust were in the process of introducing a new electronic care records system.

  • Staff reported that they did not always receive regular managerial supervision. Appraisal levels were low within the community teams.

However:

  • Forward Thinking Birmingham (FTB) is a mental health partnership established to provide care to children, young people and young adults up to age 25. Integrating the expertise of Birmingham Children’s Hospital’s (BCH) 0-16s mental health provision with Worcestershire Health and Care NHS Trust, the Priory Group, Beacon UK and The Children’s Society, Forward Thinking Birmingham aims to provide a single point of access for GPs, schools, local authorities, children, young people, young adults and families to access the right support at the right time. The partnership, which is led by BCH, went live on 1 April 2016.

  • Families and carers we spoke with said that staff had a good understanding of the individual needs of the young people they worked with.

  • Staff worked proactively with young people and their families to engage them in their care. Rates for non attendance at appointments were low.

  • The trust were part of the national schools link pilot project. The link project focussed on early intervention for young people at primary or secondary schools.

  • There was evidence of good multi agency working. Staff at the health based place of safety had also developed links with the local street triage team.

17-19 May 2016

During an inspection of Child and adolescent mental health wards

We rated child and adolescent mental health wards as good because:

  • We found Parkview clinic to be well managed and staffed by a happy staff team. Patients told us about many good experiences while they have been in the service. We observed a collaborative and inclusive team who worked well with patients.
  • There were processes in place to ensure safety when managing medications. Staff routinely carried out physical health checks. Carers told us they were kept informed about their child’s progress and we saw family therapy interventions carried out on the ward.
  • Staff within the service had a good knowledge of the patients in their care and staff across wards all worked well together. Staff were visible on wards and accessible to patients.
  • We found the leadership within Parkview clinic to be strong and innovative. The staff were team constantly striving to improve the service for patients and staff.
  • Staff had the opportunity to develop within their roles and give feedback on the service. Staff had regular team meetings and group peer supervision sessions. Staff were qualified, experienced and received appraisal however individual supervision was not routinely carried out and recorded.
  • Patient care records were clear, concise and well documented. Risk assessments and risk management were well recorded. Care plans were holistic and personalised and fully reflected patient views.

However:

  • Patients and carers told us that social activities were occasionally cancelled due to short staffing and this was disappointing for the patient. Patients also told us the food was not very good.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.