Birmingham Heartlands Hospital

Birmingham Heartlands Hospital (BHH) is part of the University Hospitals Birmingham NHS Foundation Trust which is one of the largest teaching hospital trusts in England, serving a regional, national and international population. The combined organisation has a turnover of £1.6 billion and provides acute and community services across four main hospital sites:

• The Queen Elizabeth Hospital Birmingham
• Birmingham Heartlands Hospital
• Good Hope Hospital
• Solihull Hospital

The trust also runs Birmingham Chest Clinic, a range of community services and a number of smaller satellite units, allowing people to be treated as close to home as possible.

The trust has 2,366 in-patient beds over 105 wards in addition to 115 children’s beds and 145 day-case beds. The trust operates 7,127 outpatients’ and 304 community clinics per week. The trust has over 20,000 members of staff.

At the time of our inspection, the trust was 10 months into the pandemic response to COVID-19 with over 450 COVID-19 inpatients. A number of changes to services and ward specialties had taken place since March 2020 in response to the emergency to ensure the trust was able to provide care and treatment as appropriate to the increasing number of COVID-19 patients. Throughout the pandemic, University Hospitals Birmingham NHS Foundation Trust has had a consistently high number of COVID-19 inpatients.

Concerns have been raised through enquiries and serious incident reporting about medical care services at BHH in relation to:

• Discharge processes and communication
• Venous thromboembolism (VTE) assessment and management
• Incident reporting and sharing of learning including Never Events
• Support, care and treatment for patients with learning difficulties
• Staffing
• Poor culture
• Infection control procedures
• Nutrition and hydration

These concerns led to a decision being taken to complete an unannounced (staff did not know we were coming) focused inspection on 2 December 2020. We inspected elements of our safe, effective, responsive and well led key lines of enquiry. The inspection was carried out by two CQC inspectors and one specialist advisor. During our inspection we visited eight wards and spoke with 36 members of staff including ward managers, registered nursing staff, healthcare assistants, medical staff and discharge co-ordinators. We reviewed 32 sets of records, including reviewing the electronic patient record. Following our inspection, we held a virtual interview with managers for the medical care.

Following this inspection, we did not re-rate all key questions inspected. We have only re-rated key questions where we identified a breach of regulation. Our rating of this location stayed the same. We rated it as requires improvement because:

• The service did not always control infection risk well. Control measures to protect patients, themselves and others from infection were not always used. However, equipment and the premises were visibly clean.
• Venous Thrombosis Embolism (VTE) risk assessments were not always completed on admission or by the time of the first consultant review. However, where indicated staff usually prescribed medicines to prevent the risk of a patient developing a VTE whilst in hospital within 24 hours of admission. Where VTE risk re-assessment was not indicated following the initial risk assessment, staff did not document this decision and the rationale for it on the electronic patient record. This meant staff may not be able to see the most up to date clinical information when reviewing the electronic patient record. VTE risk assessments were not always reviewed by consultants in line with national guidance.
• The service did not always have enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. However, managers regularly reviewed and adjusted staffing levels and skill mix to mitigate risks.
• Staff recognised and reported incidents. Managers investigated incidents. However, there were not consistent processes on all wards for sharing lessons learned with the whole team and the wider service.
• Staff gave patients enough food and drink to meet their needs and improve their health. However, this was not always documented in patient records where required. They used special feeding and hydration techniques when necessary. However, staff did not assess risk of malnutrition for patients admitted to the acute medical unit who had been in more than 24 hours.
• Staff supported patients to make informed decisions about their care and treatment. They knew how to support patients who lacked capacity to make their own decisions. Medical staff took time to consult family when making important decisions about a patient care where they lacked capacity. However, we did not always see evidence mental capacity assessments had been documented where indicated in patients where a do not resuscitation decision had been agreed.
• The service had systems and processes in place to safely discharge patients in a timely manner. However, we did not find these systems were always effectively implemented by staff. Discharge planning was not always commenced upon admission and completed in a structured way.
• Governance structures were in place; however, they were not always effective throughout the service. Staff at all levels were clear about their roles and accountabilities, however, not all staff had regular opportunities to meet, discuss and learn from the performance of the service.

However:

• 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 systems in place to provide an inclusive service which took account of patients’ individual needs and preferences. Staff were aware of these systems; however, we did not see evidence of them always being implemented. Staff described making reasonable adjustments to help patients access services. They coordinated care with other services and providers.
• Staff generally felt respected, supported and valued. They were focused on the needs of patients receiving care. However, some staff on wards where there had been significant changes did not feel supported by senior managers.
• Leaders and teams generally used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact.