City Hospital

City Hospital (formerly Dudley Road Hospital, and still commonly referred to as such) is a major hospital located in Birmingham, England, operated by the Sandwell and West Birmingham Hospitals NHS Trust, Serving a population of around half a million people.

It provides an extensive range of general and specialist hospital services. It is located in the Winson Green area of the west of the City. On the City site, there is also a Birmingham Treatment Centre (BTC) and a Birmingham Midland Eye Centre (BMEC).

We carried out an unannounced visit on the Medical Core service in February 16, 2017, followed by a short notice announced inspection in March 28-30, 2017, with another unannounced visit in April 6, 11-13 2017.

We have made judgements about six core services within City Hospital and rated each one individually.

Our key findings were as follows:

• Incident reporting and shared learning needed to be improved across the organisation.
• 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 trust had made a vast improvement in the end of life care service since 2014 inspection.
• We saw examples of positive multi-disciplinary working and staff told us this was consistently good across the trust.
• Infection control had improved since the inspection in 2014, however, this varied across both sites. Mortuary staff were not following the trust’s infection control policy. We were not assured the service was protecting mortuary staff and the general public that visited the mortuary from potential health and infection risks, infection control training was not included in the mortuary mandatory training.

We saw several areas of outstanding practice including:

End Of Life Care:

• 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.

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

Importantly, the trust must:

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.

Children and Young People 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.

Outpatient Department 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 that 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

In addition the trust should:

Urgent and Emergency care including BMEC:

• The trust should review cleaning schedules and include the windows above the minors’ area, which were not part of the housekeeping schedule and had not been cleaned for several months.

• The trust should review action plans from national and local audits, in particular record keeping audits to improve the quality of patient records.

• The trust should improve the communication of waiting times to patients, especially if electronic displays are not in use.

• Look for ways to improve patient privacy in the department.
• Improve the waiting area and provision of age appropriate toys and games for children and young people in the department.
• Consider introducing an electronic flagging system for vulnerable patients, such as those living with dementia or a learning disability.
• Consider participating in a wider range local and national audits in order to assess, evaluate and improve care of patients in a systematic way
• Staff should routinely assess patients’ pain on arrival to the department.
• Introduce a water dispenser in the BMEC ED waiting room to ensure vulnerable patients have quick access to water at all times.
• Implement SLA’s with other trusts so that paediatric patients are kept safe at all times
• Improve communication from executive colleagues regarding changes being proposed to the department.

Medicine:

• Review the content of the emergency resuscitation trolleys and ensure security of the contents.

Surgery including BMEC:

• Safety thermometer information should be displayed on the wards. Staff members should be aware of their ward scores.
• Competencies for nursing staff working in surgical specialisms should be revisited after their initial competency ‘sign off’ stage.
• Patients should be consented for surgery prior to arrival on the ward
• Wider learning should be promoted through complaint trends being shared amongst all areas of the trust
• Ensure all BMEC staff are aware of the duty of candour and when this would be applied, following a notifiable safety incident.
• Ensure all BMEC staff can identify a deteriorating patient; and that this is recorded in a structured way in order to monitor the effectiveness of this.
• BMEC service work towards minimising cancelled procedures due to lack of patient records.
• BMEC staff to be fully aware of when patients may require a deprivation of liberty safeguard (DOLS) application in order to ensure patients that lack capacity to consent to treatment is provided with appropriate care.

Children’s and Young People BMEC:

• That a strategy for services for children and young people is developed and embedded, and there is improved reporting about service plans and priorities.
• Review the arrangements for data collection that is specific to children and young people such as the audit plan and reporting, training and development records.
• Greater visibility and support of the children and young people service from the executive leadership team.

End Of Life care:

• The service must ensure they are preventing, detecting and controlling the spread of infections, including those that are health care associated in the mortuary department.

• The trust should ensure they have updated ‘Anticipatory Medication Guidelines’. We could not be assured staff were following the most up-to-date guidelines.

Outpatient Department including BMEC:

• Staff working in the outpatients department have their competencies checked regularly and that this is evidenced.
• Ensure that staff receive training to improve awareness of who the trust safeguarding leads are.
• The layout of the consulting rooms in the BMEC orthoptics department did not always ensure patient’s privacy and dignity were protected.
• Ensure all incidents are reported including those involving patient falls on the escalator in the Birmingham Treatment Centre.
• Patients in the BMEC outpatients waiting area are kept informed of waiting times and late-running clinics.
• Reassess the layout of the BMEC coffee shop seating area to ensure people can move about safely, and sufficient space is provided for people using wheelchairs.
• All staff have annual appraisals.
• There are chaperone notices in the outpatient’s department.
• There is clear signage in the outpatient’s department.
• Staff complete training to raise awareness and improve skills for working with people with learning disabilities.

Ted Baker

Chief Inspector of Hospitals