Archived: Heart of England NHS Foundation Trust

Updated 2 August 2017

Heart of England Acute sites

• There are just over 1300 beds at this hospital at the time of our inspection.

• This trust is a Foundation Trust, this means

• At the time of the inspection the trust was starting the process to seek approval to merge with University hospitals Birmingham Foundation Trust.

• The trust has three acute sites situated in the east, north and southeast of the city of Birmingham.Catering to a wide demographic population

• We used the intelligence we held about the hospital to identify that we needed to inspect of the Emergency department (ED), Medicine, Surgery, Critical care and Outpatients and diagnostic imaging. In relation to Critical Care we inspected this service as it had been rated good previously and wanted to see if it had improved further.

• We have inspected because we needed to be assured that the trust was on an improvement trajectory.Intelligence from the trust and nationally available reports along with information from the public, helped us to identify the services for which we had concerns.

• The trust had two dialysis satellite units within the community, offering 57 dialysis stations to support people with acute kidney failure. Both were nurse led units, supported by the main unit within the hospital (we did not inspect the hospital unit).

• Patients referred to the service are supported to stay at home following admissions and to prevent further admissions by teams of multidisciplinary staff based in the community. This was mostly based in the Solihull area.

• The trust also has a dedicated chest clinic service which operates from the centre of Birmingham offering a number of specialist clinics including Rapid Access for suspected lung cancer, Occupational lung disease, Tuberculosis (TB) and Thoracic surgery.

Updated 2 August 2017

Heart of England Foundation Trust is a large NHS provider of acute hospital and community services in Birmingham and Solihull. The hospitals are in the East and North of Birmingham and one smaller site in Solihull West Midlands. There is also the Birmingham Chest Clinic which is in the centre of Birmingham. The trust has some community services in Solihull. We did not inspect the community services or the Chest Clinic. The three acute sites are Birmingham Heartlands Hospital, Good Hope Hospital and Solihull Hospital. Along with the community service the trust serves approximately 1.2m people. The Birmingham Heartlands site is where the trust headquarters are located.

We carried out this unannounced responsive inspection because the trust was in breach with regulators Monitor, and we had received intelligence which warranted our response and so we arranged the inspection. The inspection took place between 08 and 11 December 2014. We had inspected the service in November 2013 and the trust was still working through compliance action plans. While progress has been made since our last visit, this is limited and not yet sufficient.

We specifically focussed on A&E, Medicine, Surgery, Maternity and Outpatients Departments on all three sites.

This inspection was an unannounced responsive inspection. The purpose of the report is to share with the trust and the public the evidence we gathered during that inspection. It is also important to note that at the time the trust leadership was in transition with many changes within the trust executive team, some of whom were in interim posts. This had been precipitated by the previous Chief Executive resigning in November 2014.

While we found some evidence of progress since the last inspection we did find in others no improvements or deterioration.

Our key findings were as follows:

• Widespread learning from incidents needed to be improved.
• Appraisals for staff were not widely undertaken achieving 38% compliance at the time of our inspection; which would equate to 57% by year end.
• Staffing sickness and attrition rates were impacting negatively on existing staff.
• The poor patient flow mainly in BHH and GHH was having negative impacts across all the core areas we inspected. For instance the number of patients having to wait in recovery more than 30 minutes was high.
• Referral to treatment times were not always met for people. It was present on the Board assurance framework and posed a reputational risk to the trust as well as a risk to patients waiting for treatment.
• Discharge arrangements required improvement; we saw that only 35% of patients were discharged on or before their planned date of discharge.
• The care of the deteriorating patient was generally managed well.
• Arrangements for patients with reduced cognitive function were not always effective. This meant that some patients did not receive the level of care and support they required.
• The leadership was in a transition phase with some in interim posts including Chief Executive and Medical Director.
• The culture within the trust was one of uncertainty due to the number of changes which had occurred.
• Staff could not communicate the trust vision and strategy.
• Governance arrangements needed to be strengthened to ensure more effective delivery.
• IT systems needed to be improved to ensure reporting was accurate. The ability of the trust to report against activity was not always available for use at trust level or to their commissioners.

We saw several areas of outstanding practice including:

• On the Acute Medical Unit (AMU) at Birmingham Heartlands Hospital (BHH) local complaints resolution was very responsive to patient’s needs. The complainant was invited to a meeting and given a recording of the discussion. This appeared to resolve complaints quickly.
• AMU, Ambulatory Care, wards 10, 11 and 24 on the BHH site provided excellent local leadership, services were well organised, responsive to patients individual needs and efficient which resulted in excellent patient outcomes.
• The Practice Placement team provided excellent links between the trust and the University in supporting more than 600 student nurses across all three hospital sites.
• Sexual health team demonstrated how they used information such as audit and patient feedback to improve services to patients.
• We saw caring was good across the trust. We did not review caring in this report; but had no concerns about the caring of staff in the trust.

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

• BHH Emergency department was overcrowded with poor flow, leading to a high stress, high risk environment for both patients and staff.
• Arrangements for patients who required mittens were not undertaken to maintain patient’s safeguards. The hospital staff was applying mittens to some patients (to prevent removal of nasogastric tubes etc) without the necessary Deprivation of Liberty Safeguard assessments being in place.

Importantly, the trust must:

• The trust must take effective action to achieve consistent staff compliance of infection control procedures within the emergency department.
• The trust must address the ambivalence held by staff about reporting incidents as they may be underreporting and trust could miss important trends.
• The trust must ensure that staff are clear about clinical responsibility for patient’s awaiting handover by Ambulance services in the emergency department at Heartlands.
• The trust must take effective action to address the crowding in the majors area of the ED department and ensure that staff on duty can see and treat patients in a timely way.
• The trust must ensure all patients requiring items of restraint such as hand control padded mittens are supported with a mental capacity assessment, a DoLS and are regularly reviewed by the MDT which is recorded in the patient’s notes and mittens are replaced when soiled. A consistent practice must be adopted across the trust.
• The trust must replace or repair essential equipment in a timely manner.
• The trust must provide sufficient staff to operate the second obstetrics theatre at night, and prevent delays occurring.
• The hospital must improve the information available to outpatients departments to ensure that these are monitored and action taken to improve services through audit, trending and learning.
• The trust must review the operation of rapid assessment of patients to improve its consistency and effectiveness.
• Improve the environment of the transfer corridor used to transport patients and dispose of refuse appropriately at the Good Hope site.
• The trust must improve arrangements regarding patients following surgery having to wait in recovery over 30 minutes.
• The trust must ensure all fire doors and exits are free from clutter.

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

As a result of this, the trust will be subject to regulatory action as requirement notices and a comprehensive inspection will be carried out to confirm this.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Updated 2 August 2017

We judged that community adult services (CAS) were good.

• Community adult services (CAS) achieved a good standard of safety. This was because there were good methods of reporting, investigating and learning from incidents and near misses that were well understood by staff and embedded in their daily work. There were plans to deal with major incident or events that would disrupt the delivery of care. CAS staff were making appropriate adult safeguarding referrals. There were processes and systems that protected patients from the risk of infection, and the risks associated with equipment used in their care and treatment. There were safe systems of medicines management. Records were accurate, comprehensive and current, and supported the delivery of safe care. Most mandatory training had been completed across CAS against a trust target of 85%. Staffing numbers were reviewed regularly, an active recruitment programme was in progress and arrangements to ensure any staffing shortfalls were managed on an on-going basis to minimise the impact on patients.

• National guidance from government, the National Institute of Health and Care Excellence (NICE) and professional bodies were complied with and that staff showed awareness of relevant guidance in their work. Staff were actively engaged in activities to monitor and improve quality and outcomes. Quality of care was monitored through audits, which informed the development of local guidance and practice. Patients could access all professionals relevant to their care through a hub system of integrated multi-disciplinary teams (MDT). Patients’ care was co-ordinated and managed. There were systems to gain people’s consent prior to care and treatment. Where patients lacked the capacity to give consent, there were arrangements to ensure that staff acted in accordance with their legal obligations.

• Patients and carers were positive about their experience of care and treatment, and feedback gathered by the organisation showed good levels of satisfaction. The average score for people who responded that they would be likely to recommend community services was 98%. We observed all staff responding to people with kindness and compassion. Patients told us they were treated with dignity and respect, and that they were involved in the planning and delivery of their care to the extent they wished to be.

• The involvement of other organizations and the local community was integral to how services were planned and ensured that services met people’s needs. CAS had a model of integrated community hubs to ensure people received joined up working that was responsive to their individual needs. There was provision to ensure that essential services were available out-of-hours, and there were no major issues with waiting lists, with the exception of podiatric surgery, where a few patients exceeded the 18 week wait target due to a lack of available anaesthetists.

• Work was in progress to give community adult services a clear strategic direction and staff felt engaged with the strategy development. There was evidence of innovative practice including podiatric staff working in a MDT in dermatology for patients with  epidermolysis bullosa (EB), an inherited genetic condition that makes skin fragile.
• The leadership drove continuous improvement and staff were accountable for delivering change. There was a clear proactive approach to seeking out and embedding new and more sustainable models of care, for example a model of community hubs. There were systems to ensure good governance and monitoring of standards and performance. There was an effective escalation and cascading of information from the board to front-line workers, and vice-versa. We found that there was a positive culture, with staff and managers feeling proud of their work and achievements and speaking well of their colleagues and leadership.