All inspections: Sandwell and West Birmingham Hospitals NHS Trust

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

The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
The service used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. The service used information to improve the service.
The service mostly controlled infection risk well. Staff generally kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
The service had suitable premises and equipment and looked after them well.
Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care.
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.
The service had 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 provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural and other preferences.
The service monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.
The service made sure staff were competent for their roles. Managers appraised staff’s work performance.
Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
Staff always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. All staff had access to an electronic records system that they could all update.
Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
Staff involved patients and those close to them in decisions about their care and treatment.
Staff provided emotional support to patients to minimise their distress.
The trust planned and provided services in a way that met the needs of local people.
People could access the service when they needed it. Waiting times from treatment were and arrangements to admit, treat and discharge patients were in line with good practice.
The service took account of patients’ individual needs.
The trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.
Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
The trust used a systematic approach to continually improve the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.
The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
The trust collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.
The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.
The trust was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation.

However,

The service provided mandatory training in key skills to all staff, however not all staff were fully compliant in training the trust deemed essential for safe and efficient service delivery and personal safety.
Emergency resuscitation trolleys had no security tags on the drawers to alert staff to tampering with the content. Resuscitation trollies were therefor not tamperproof
Staff did not achieve uniformly high standards in recording and communicating decisions about CPR and that DNACPR forms in line with best practice.
When monitoring and scoring vital signs nurses did not always take urgent action to review the care of the patient and call for specialist help when necessary.
Mental capacity assessments completed by staff were not always detailed, compliant with legislation and best practice, or undertaken in a way and at a time that recognised patient’s abilities.
Most but not all staff were up to date with their yearly appraisal.
Care plans did not describe the care needs in an individualised way.
Although the service treated concerns and complaints seriously, the time taken to investigate complaints was not in line with trust policy.
Ward risk registers did not reflect all risks staff identified in the area.

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

The Sandwell General Hospital and City Hospital were rated as requires improvement.
In many services, safe was rated as requires improvement and in six services well-led was rated as requires improvement.
Well-led for services for children and young people was rated inadequate.

Sandwell and West Birmingham Hospitals NHS Trust is a provider of both acute hospital and community services for the people of West Birmingham and across six towns in Sandwell, serving a population of around half a million people.

Services are provided from two main acute locations, City Hospital (to the West of Birmingham)l and Sandwell General Hospital. On the City Hospital site there is also the Birmingham Treatment Centre (BTC) and a Birmingham Midland Eye Centre (BMEC). The trust also provides community services to include Adult services, End of life care, Inpatient services at Rowley Regis Hospital and Children and Young people services. For the purposes of this inspection we visited two community services; End of life care services and Inpatient services.

We inspected this trust using our comprehensive methodology in October 2014. At that time we rated the trust requires improvement overall, and we had particular concerns about Medical services, Surgery services and Outpatient and Diagnostic Imaging services across both City Hospital and Sandwell General Hospital sites. Since our last inspection, we have seen that the trust has made significant improvements in a number of areas, we saw some areas of outstanding practice, however there is still more work for the trust to do.

We carried out an unannounced visit to Medical service across both hospital sites on 16 February 2017, because we had concerns about safety and quality of care, followed by a short notice announced inspection on 28- 30 March 2017. This inspection included the following core services; Emergency Department (ED), Medical services, Surgery services, End of Life Care services, Outpatient and Diagnostic Imaging services and the Birmingham Midland Eye Centre. Following the inspection, we returned to carry out an unannounced inspection on 6, 11, 12 and 13 April 2017.

We made judgements about eight core services across acute and community,

Our key findings were as follows:

Incidents were reported, investigated, and learned from to improve safety and staff were committed to being open and honest with patients when things went wrong but this varied across both sites and core service.
The trust held 10 quality improvement half days (QIHD) per year during which time staff shared learning and attended relevant training.
Infection control had improved since the inspection in 2014, however, this varied across both sites.
Urgent and emergency care service trust wide met the RCEM standard of patients being treated within one hour of arriving.
The trust’s monthly average total time in ED for all patients was consistently lower than other English trusts and this was a stable position.
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.
The hospital routinely collected and monitored information about patient care and treatment and their outcomes.
There were innovative approaches to providing integrated person-centred pathways of care that involved other service providers, particularly for people with multiple and complex needs.
Multi-disciplinary team (MDT) working was evident throughout the hospital.
The trust end of life care service had a holistic approach to patient care, 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.
The mortuary on both sites had improved its environmental condition since inspection 2014
The trust provided access to care and treatment 24 hours a day, seven days a week.
An IRMER committee monitored, analysed and reported incidents in the diagnostic imaging department. All IRMER documentation was in place a vast improvement since inspection 2014.
We had concerns for ward D26 at city hospital around care and attitude of staff towards the patients.

We saw several areas of outstanding practice including:

The palliative and end of life care service ensured that patients and their families were involved in their care and their choices and preferences were upheld, including where they would prefer to be for their care and when they died.
The palliative and end of life care service integrated coordination hub acted as one single point of access for patients and health professionals to coordinate end of life services for patients.
The service provided access to care and treatment in both acute hospitals and in the community, seven days a week 24 hours a day.
The service reacted speedily to referrals by providing an urgent response team in order to meet patient’s needs quickly.
Staff went the extra mile to ensure patients received the right care in the right place at the right time.
Staff showed great compassion, empathy and an understanding of patient’s needs and preferences.
Newton 4 at Sandwell displayed a high-level person centred care approach. The staff on this ward were very enthusiastic and passionate about the care they delivered and the patients they served. There were a number of innovative practices developed on this ward, which included the breakfast therapy club to aid with patient rehabilitation, rewarded by the stroke association. The development and implementation of the JEL model for staff progression, the development of the delirium pathway and of the patient care bundles to aid patient progression and so patients could own their own goals.

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

Importantly, the trust must:

Sandwell General site

Emergency Department

The trust must take action to ensure storage and availability arrangements of emergency medicines required for resuscitation follow Resus Council Guidance and robust arrangements are put in place to manage the risk and ensure that medicines for resuscitation were protected from tampering.
The trust must take action to improve the standard of records completed by doctors when patients were admitted to wards from the ED compromised the clerking process and increased risk to patients.
The trust must take action to ensure patients in the ED receive treatment within one hour of arriving in line with the Royal College of Emergency Medicine (RCEM) recommendation.
The trust must take action to ensure there is a clearly agreed and resourced system in place for safely managing the condition of patients queuing on trolleys when the ED is very busy.
The trust must take action to ensure staff identify patients at risk of sepsis and follow the sepsis pathway in place.
The trust must take action to ensure doctors use the appropriate proforma in place for effective clinical pathways.
The trust must take action to ensure sufficient substantive registrar cover overnight for the safety of patients.
The trust must take action to ensure there is a designated appropriately safe room available within which to care for patients with mental ill health
The trust must take action to ensure the security and safety of staff working in the ED at all times.
The trust must take action to ensure unplanned re-attendance rate to the ED within seven days is reduced.
The trust must take action to ensure information about patients’ assessment and condition recorded by consultants and doctors is sufficiently detailed, precise and legible.
The trust must take action to ensure patients are admitted, transferred or discharged within four hours of arrival in the ED.

The trust must take effective action to mitigate the increasing risks to patients from overcrowding in the ED.

Medical Care service

The trust must ensure that all staff across medical services are up to date with basic life supporting training.
The trust must have assurance that the temporary staff being used are competent to fulfil the role.
The trust must ensure that resuscitation medicines and equipment are stored in a way to protect from tampering and that storage and availability is consistent across all areas within the medical service.
The trust must ensure that the guidance from the Resuscitation Council (November 2016) is being followed.
The trust provider must ensure there is sufficient storage for equipment on medical wards to avoid delay in relevant equipment being received by ward staff, and to avoid out of service and in service equipment being stored together.
The trust must ensure there is sufficient staffing and skill mix to meet safe staffing requirements on medical wards.

Surgery

Ensure measures are in place to prevent further Never Events to protect patient’s safety.
Ensure that records of care and treatment provided to patients are accurate and complete.

Outpatient Department and Diagnostic Imaging
Ensure resuscitation trolleys are checked daily, medications and fluid bags are stored appropriately and trolleys are secure and tamperproof.
Ensure staff are up to date with their safeguarding mandatory training.
Ensure all staff undergo regular assessments to ensure they are competent and confident to carry out their roles.

City Hospital site

BMEC-Emergency Department

Increase availability of specialist medical staff and anaesthetists to minimise the risk that children, particularly those younger than three years of age, who attended department receive timely and appropriate treatment.
Robust policies and procedures are in place to manage the effective security of prescription forms at a local level.
The storage of fluids are tamper proof, in line with Resuscitation Council guidelines.
Patient records must meet standards for general medical record keeping by physicians in hospital practice.

Medicine:

Ensure compliance with the Mental Capacity Act (2005) is documented.
Ensure attendance at mandatory training is improved.
Take steps to reduce delays in the patient journey and ensure people are able to access care and treatment in a timely way.
Improve the consistency of multi-disciplinary processes and ensure the implementation of consultant led board and ward rounds.
Ensure patients have access to translation services when required.
Ensure governance structures are embedded and a structured approach is taken to the identification and management of organisational risk.

Surgery including BMEC:

Ensure measures are in place to prevent further Never Events to protect patient’s safety.
BMEC mandatory training targets for all clinical staff are met and recorded.

CYP BMEC:

Improve local governance and ensure risks to the service are escalated, recorded, acted upon and reviewed in a timely manner.
Medical staffing meets needs of patients and the service.
Review the storage of emergency drugs and equipment for children and young people
Age appropriate facilities are provided with separation of adult and children waiting areas and treatment areas.
Mandatory training targets are met and recorded including paediatric life support.
A framework for staff to develop and demonstrate competencies to care for children is in place.

OPD including BMEC:

Resuscitation trolleys are locked and secured with tamperproof tags.
Patient notes are kept securely and confidentially.
Sharps bins and clinical waste are stored securely and safely.
Consulting rooms in BMEC protect patients’ dignity and privacy, and prevent people from overhearing conversations between staff and patients.
There are improvements with staff completion of mandatory training.
All staff who carry out root cause analyses are trained to do so.
The consulting rooms in the BMEC orthoptics department were large, and two or three patients underwent consultations at the same time, only separated by screens. Patients were able to overhear conversations between staff and other patients in the room. Staff told us they were not able to protect patients’ dignity and privacy due to the way the rooms were set up, but they had one single room they were able to use if patients expressed concern. We asked staff if they told patients about this facility and if staff offered it to patients for their consultation; Staff told us that the patients only used the room if they raised the issue.

Community Inpatients;

Review the process for assessing and documenting assessments in accordance with the Mental Capacity Act 2005.
Ensure patients are not deprived of their liberty for the purpose of receiving care or treatment without lawful authority, in line with Deprivation of Liberty Safeguards 2010.
Ensure that all staff have regard for the protected characteristics under the Equality Act 2010, and support patients in a way that is respectful and promotes their dignity.
The service must comply with the requirements of the Data Protection Act 1998, and ensure staff keep service user’s personal data safe and secure at all times.
Ensure risk assessments and safety reviews are considered and undertaken where changes to service provision is made.
Ensure risk registers are accurate, contemporaneous, and reviewed and update routinely, as required.

Ted Baker

Chief Inspector of Hospitals

Palliative and end of life services at within Sandwell & City Hospitals NHS Trust provides an integrated service within both within Sandwell & City Hospitals and the community. The community include patients own homes, home from home beds, home from hospice beds and the Heart of Sandwell Day Hospice in Rowley Regis Hospital.

We have rated end of life services overall as outstanding. We rated the safe domain as good and effective, responsive, caring and well led domains as outstanding. This is because:

Experienced staff provided a compassionate and responsive evidence based service for end of life care patients.
The service provided comprehensive joined-up care with access to care and treatment in both acute hospitals and in the community, seven days a week, 24 hours a day.
The service followed evidenced based guidance incorporating NICE Guidance including NICE QS13 End of Life Care for Adults (Nov 2001/updated Mar 2017) and The Five Priorities for Care of the Dying Person (Leadership Alliance 2015).
Staff were knowledgeable about the trust’s incident reporting process and we saw concerns were investigated and learning shared.
The service had one single point of access for patients and health professionals to coordinate end of life care services for patients known as the Hub. This meant patients received the right care at the right time in the right place.
The palliative and end of life care service was very well developed across the trust and held in high regard both by staff within the trust and other agencies.
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.
There was a clear governance structure from community services 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.
Patients were involved in their care and were enabled to make choices. This included choosing the place where they wished to receive palliative care and where they would prefer to die. The palliative and end of life care team ensured that arrangements weremade quickly so they could be within their preferred place of care.
Advanced Care Plans and Supportive Care Plans (SCP) 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.

However:

The trust’s ‘Anticipatory Medication Guidelines’ was due for review in September 2016 but no updated guidance was available. We could not be assured staff were following the most up-to-date guidelines.

Overall rating for this core service

We rated the service inadequate because:

Medicine management was a concern at Rowley Regis, with 28 medication related incidents in 2016. Staff reported an incident related to medication on 21 days between 1 January and 16 February 2017.
Staff did not undertaken mental capacity assessments in accordance with the requirements of the Mental capacity Act 2005. We found patients whose liberty had been deprived without staff following the requirements of Deprivation of Liberty Safeguards 2010.
The service used a high level of agency staff due to a lack of substantive staff, and ward managers did not have oversight of the competencies of the agency staff working at Rowley Regis Hospital.
We found three of the four care plans reviewed did not contain the most recent best practice, national guidance or evidence base. This could result in staff delivering care that was not in line with current guidance.
The identification and assessment of risk was inconsistent across the service. We found one example of staffing changes and another relating to the availability of emergency equipment that had not been risk assessed.
Local risk registers lacked detail and we were not assured on the review of risks, both locally at ward level and across the wider group.
We found a lack of public engagement, with senior ward nurses stating that patient focus groups used to happen however, these stopped in 2016.
Staff did not consistently promote patients privacy and dignity during nursing handovers as these took place at the reception desk in view of other staff, visitors and patients. We found handover sheets and test request forms containing patient identifiable information left unattended on reception desks on Henderson ward, Eliza Tinsley ward and McCarthy ward.
Staff demonstrated a mixed approach to the requirements of the Equality Act 2010. Staff did not consistently utilise alternative communication methods and had mixed knowledge of how to access religious leaders from faiths other than Christianity. Medical staff asked had a blanket approach to reviewing patient care based on their age. Nursing staff had a mixed understanding of how to support patients that were transgender, non-binary gender or had a sexual orientation other than heterosexual.

However:

We found nursing and therapy documentation to be detailed, accurate and timely. However, we did find nursing staff using “N” during night shifts instead of documenting a specific time and date.
Staff complied with relevant infection prevention and control requirements and we found good standard of cleanliness throughout the hospital.
We found good multidisciplinary working and discharge planning on all three wards visited.
Staff delivered care in a kind and compassionate way. Staff involved patients and those close to them in decisions about care and discharge planning.
Senior staff planned services to take account of the needs of the local population.
The service received a low number of complaints, six in total, in 2016. Group clinical governance meetings discuss all complaints.
Local leaders were visible within clinical areas, and we saw regular engagement with staff, patient and visitors throughout the inspection.

Children and young people (CYP) services was rated outstanding overall. During the inspection we met with managers, staff, children and parents in a range of community settings. We observed care being delivered in mainstream and special schools, clinics and in children’s own homes. We saw excellent innovations in practice to improve care and treatment for children and young people for example a ‘tactile cue’ called ‘TaSSeLs’ and a computer ‘app’ to help children learn and develop. CYP Staff worked with other professionals and external organisations such as CAMHs (child and adolescent mental health services) and social services.

There was evidence that the services for children and young people were delivered in line with best practice guidance and local agreement. Staff were dedicated, professional and well supported. We saw strong local leadership across all community CYP services. Staff told us that they were a valued member of their respective teams. We saw that care was child centred and individualised across all CYP services.

There was an effective system in place to report and learn from adverse incidents, errors, near misses and complaints. We saw care was delivered to promote dignity and respect, and found staff were very responsive to children and their families’ needs.

There was a robust safeguarding process in place and infection control audits demonstrated that infection control guidance was effective. We saw infection control practices across CYP services was good. Environmental observations and reviews of records showed there was a high level of cleanliness across the sites and the availability of safe, clean equipment was generally good.

Generally, staffing levels across CYP services were good, we saw the trust had on going challenges with recruitment of health visitors, and no assessment of ‘fine motor skills’ for children with complex needs by occupational therapists due to a capacity issue. However, this did not adversely affect patient satisfaction and the trust had a robust recruitment plan in place.

Management of medicines were in line with trust policy. The trust supported staff to ensure that their mandatory training needs were met and individual training needs identified. Staff were given supervision and annual appraisals. Staff expressed satisfaction with the levels of support from their local managers.

The leadership of CYP services was supportive and nurturing, senior managers were visible and well liked. Staff told us they thought the executive team “did a good job” in leading the trust and there was strong communication networks throughout CYP services with staff feeling well informed.

We saw local and senior managers encouraged and supported staff to be creative with innovations in practice. CYP services received few complaints, and people we spoke to during the inspection were very complimentary about the staff and the quality of the service they received.

Sandwell and West Birmingham Hospitals NHS Trust is a provider of both acute hospital and community services for the west of Birmingham and six towns in Sandwell. It serves a population of around half a million people. There are two main acute locations: City Hospital and Sandwell General Hospital; there is also the Birmingham Treatment Centre on the City site. The trust provides community services in the form of inpatients at the Leasowes Intermediate Care Centre and Rowley Regis Hospital, alongside other community services such as district nursing and community palliative care. All community services are offered in the Sandwell area. The Birmingham and Midland Eye Centre based on the City site is a specialist service which will be scheduled for a full inspection separately. Please note we did look at its outpatient department as part of the outpatient core service.

We carried out this comprehensive inspection because the trust is known as an aspirational trust wanting to become a foundation trust. The inspection took place between 14 and 17 October 2014, and unannounced inspection visits took place between 25 and 30 October.

Overall, this trust requires improvement. We rated it good for caring for patients and effective care but it requires improvement in being responsive to patients’ needs and being well-led. We rated the safe domain as inadequate.

Our key findings were as follows:

Staff were caring and compassionate, and treated patients with dignity and respect.
Shared learning from incident reporting needed to be improved across the organisation.
Infection control practices were generally good but there were pockets of poor practice that needed to be addressed.
Medicines management was inconsistent. Pharmacy support was good and staff valued the input of the pharmacists. However, across the trust, the safe storage of medicines was not robust. This was an area in which the trust had failed to meet its targets for 2013/14.
The trust had consistently failed to meet the national target for treating 95% of patients attending the accident and emergency (A&E) department within 4 hours.
Generally community services were good, but required improvement for safety.
We were concerned about wards D26 and D11 at City Hospital, which were not meeting the basic care needs for patients.
The trust had recognised that end of life care was an area for development for the Bradbury House Day Hospice.
The mortuary on both sites had long-standing environmental issues that needed to be addressed.

We saw several areas of outstanding practice including:

The iCares service within the community and the diabetic service. These were outstanding and had received national recognition. Critical care services were good overall, with both staff and patients feeling well supported.
The compassionate and caring dedication for end of life care with regard to a minor, which was rated as outstanding, especially how the service used the wider healthcare team to meet the needs of the individual. We were confident that this level of support would be repeated in a similar situation.

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

Importantly, the trust must:

review the levels of nursing staff across all wards and departments to ensure that they are safe and meet the requirements of the service;
ensure that all staff are consistently reporting incidents, and that staff receive feedback on all incidents raised so that service development and learning can take place;
ensure that all patient-identifiable information is handled and stored securely;
follow through from findings of safety audit data, and follow up absence of safety audit data;
address systemic gaps in patient assessment records;
take steps to improve staff understanding of isolation procedures.

There were also areas of practice where the trust should take action, and these are identified in the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

The inspection team visited four end of life community services. In total, we spoke with 10 patients and 25 staff members, including palliative medicine consultants, specialist palliative care nurses, district nurses, community nurses, healthcare assistants, an inpatient manager and volunteers.

The hospice at home team, based at Bradbury House Day Hospice, is a specialist palliative care service providing care and support for patients and families in Sandwell.

Bradbury House Day Hospice is run by a palliative care nurse specialist, healthcare assistant and volunteers, offering day care, support and advice for patients with a life-limiting illness in Sandwell. The hospice operates Monday to Friday 8.30am to 3.30pm, and is closed on Thursdays.

District nurse services provide 24-hour nursing care to people at home with a life-limiting illness in Sandwell.

The Leasowes Intermediate Care Centre provides two beds for people with a life-limiting illness.

End of life services were rated good within the trust. We identified areas where staff provided excellent care and showed a willingness to ‘go the extra mile’ for patients and their families. We heard numerous examples of staff working together and overcoming challenges to ensure the best possible outcomes for patients receiving end of life care.

Staff ensured that patients were safe by assessing and responding to risks appropriately, learning from incidents and having access to clean and well-maintained equipment. Records reflected patients’ individual needs and followed the end of life pathway as a continuous journey until patients reached the end of their lives.

Services delivering end of life care were effective in meeting patients’ needs. This was reflected with individualised care plans and robust risk assessments throughout a patient’s journey. Staff across all end of life services were competent and knowledgeable, and we saw evidence of multidisciplinary working at its best in achieving optimum outcomes for patients and their families.

Teams worked hard to ensure that care was delivered with compassion, dignity and respect. Patients and their families were included in the decision-making process from individual likes and dislikes to preferred place of care and, eventually, where a patient would prefer to die.

End of life services responded well to patients’ cultural and spiritual needs, and the end of life integrated care pathway supported patients’ and families’ wishes from time of diagnosis to time of death. Staff worked proactively, breaking down barriers to ensure that patients received care at the right time and in their preferred place.

The trust’s vision for end of life services was clear, with proposed clinical developments planned for community services that were currently in a transitional phase of redevelopment. Teams were well managed both locally and strategically, and staff felt supported; in most areas, staff also felt listened to. Teams and managers collected data and conducted clinical audits to measure the quality of care they delivered and how teams performed in line with the national End of Life Care Strategy (Department of Health, 2008) for ongoing service improvement.

There were systems in place for reporting and investigating incidents involving patients, and evidence that learning from incidents occurred within the service. Staffing levels were not routinely reported as incidents in the same way.

Both community inpatient services (the Leasowes Intermediate Care Centre and Henderson Ward at Rowley Regis Hospital) were clean and well maintained. Equipment had been cleaned, labelled, and was ready to use.

Staffing levels were problematic in the Leasowes Intermediate Care Centre, particularly the nursing staffing numbers at night-time. This was having an impact on patients who were waiting for long periods for their call bells to be answered. It was also a risk to the safety of patients at the centre. The issue had been recognised by the trust and permission given to increase the establishment by one qualified nurse overnight. However, at the time of our visit, no action had been taken to increase the staffing levels. They were subject to review across the trust and the number of therapists was also being increased at both services. Some patients told us about the lack of staff, particularly during the night.

All staff received mandatory training, and an emphasis was being placed on the completion of performance development reviews and the effective management of attendance. Risk management processes were in place.

There was good evidence of multidisciplinary team working across therapies, nursing and medicine, and good integration of care for patients at both services. Staff offered compassionate care and respected the dignity and privacy of patients. Risks were identified around nutrition and hydration, and patients enjoyed a choice of food and drink.

Services were organised to respond to the individual needs of patients, including those requiring dementia care or interpreting services. Patients were involved in setting out their goals for rehabilitation, and therapies were delivered with care, professional expertise and compassion. Patients we spoke with were happy with the care and treatment they had received.

We saw good evidence of learning from incidents, but could not be assured that it was universal.

At Rowley Regis Hospital we found prescription medicines that were not appropriately stored, together with out-of-date clinical equipment.

Staff were competent to carry out their role, and identified and responded to patient risk in a way that ensured patient safety. There were vacancies across the service, which meant caseloads were increased for some nursing and therapy teams. Staff told us that they were happy to come to work, and spoke positively of the contribution they made to patient care.

The service was effective and caring. Care and treatment was evidence-based, and staff followed current best practice recommendations. There were positive examples of multidisciplinary working across internal services, and between local healthcare organisations. All patients and carers spoke positively about the care provided, and we observed staff delivering compassionate care.

The service was responsive to patient need, and patients were treated in their own homes or community clinics where possible. Services engaged with patients to gain feedback and improve service provision.

Many services had practices in place to prevent unnecessary hospital admissions. An example of this was the integrated care services (iCARES), an open access integrated care service that managed adults with long-term conditions.

Staff felt that hospital services and senior managers did not understand the role of community services, and many staff felt that community services were the 'poor relation' compared to acute services.

There were notable examples of innovation; these included the community alcohol service that had integrated into the trust, and the Cape Hill district nursing team, who participated in an 'Aspiring to Clinical Excellence' project. The service promoted clinical audits, projects and research pilots.