University Hospitals Birmingham NHS Foundation Trust is large teaching hospital with a reputation for quality of care, information technology, clinical training and research. It provides care from the Queen Elizabeth Medical Centre which is a new hospital on the site of the original. At the time of our inspection some wards in the old Queen Elizabeth hospital building were open. The trust also provides sexual health services from a number of locations across Birmingham.

The new Queen Elizabeth Medical Centre opened in June 2010 and was constructed under the public sector private finance initiative.

The Trust provides direct clinical services to over 900,000 patients every year, serving a regional, national and international population. It is a level 1 trauma centre, and is a regional centre for cancer, trauma, renal dialysis, burns and plastics; and provides a series of highly specialist cardiac, liver, oncology and neurosurgery services to patients from across the UK.

We inspected this service in January 2015 as part of the comprehensive inspection programme.

We visited the trust on 28, 29 and 30 January 2015 as part of our announced inspection. We also visited unannounced to the trust until Friday 13 February. This included visits to critical care, accident and emergency and medical care services.

We inspected all core services provided by the trust (note the hospital does not provide maternity nor children’s services). We also inspected sexual health services as an additional core service of Outpatient’s.

Our key findings were as follows:

• Services in the trust had strong clinical and managerial leadership at many levels.
• Staff were highly engaged with the trust and felt valued. This gave them a strong sense of purpose during their clinical interactions with patients.
• A culture of local and national audit and analysis was encouraged. This led to change and improvements in practice and care.
• Critical Care services provided outstanding effective outcomes focused care and leadership.
• Medical Care and End of Life Care services were outstanding in their responsiveness to patient’s needs.
• Urgent and Emergency Care Services had poor infection control practices.
• In surgery, we saw that safety checks of resuscitation equipment were not systematically carried out and some records were not completed appropriately
• 55% of staff waited over 30 minutes for their scheduled appointment in outpatients. During our inspection six patients waited over two hours.
• Staffing levels were good across the trust.

We saw several areas of outstanding practice including:

• We saw examples of excellent care and innovative practice, such as the interaction of trauma team with members from different disciplines.
• Urgent Care services ‘clinical quality and safety’ newsletter which informed staff of quality and safety issues such as earning from incidents, directed them to learning resources through e-links and shared information. It reduced the burden of emails to staff having this in one single issue.
• Critical Care Services had specialist ‘burns shock’ rooms (specially designed rooms with self-contained care and treatment facilities) to support best outcomes for these patients.
• Reduction in length of stay and reduction in use of a ventilator through physiotherapy multidisciplinary intervention in critical care.
• The trust used pioneering treatments to achieve positive outcomes for surgical patients with complex trauma cases and transplant needs.
• Introduction of sleep packs and hearing aid storage boxes to all patients who require them.

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

Importantly, the trust must:

• Improve the infection control issues within Urgent and Emergency Services; both in clinical practice and in cleaning schedules.
• Resolve the poor labelling practices of blood samples in Urgent and Emergency care services.
• Increase focus on delivering the 18 week Referral to Treatment target.
• Improve safety checks of resuscitation equipment and recording in surgery
• Ensure the cleaning and hygiene in the ward based regeneration kitchens is consistently maintained.
• Reduce waiting times in the outpatients department
• Increase consultation time in outpatients particularly for patients with complex conditions
• Improve pain relief response in Urgent and Emergency Care services

In addition the trust should:

• Ensure the responses to the issues on West 2 are sustained, especially with regard to staffing levels.

Professor Sir Mike Richards

Chief Inspector of Hospitals

This was not an inspection of all of the services provided by the Trust.

When we last visited the trust in July 2013 we identified some concerns about how the care provided to patients, was checked and monitored by senior staff on wards and units. Whilst the hospital looked into all serious issues, some routine checking to ensure people received planned care and treatment was not evident.

When we visited the hospital on 28 November 2014 we found improvements had been made. We specifically focussed on how the hospital managed the care of patients at risk from pressure ulcers (an ulcer as a result of pressure damage) and we looked at how the risk of poor nutrition was managed. We found the trust had taken steps to reduce the incidence of preventable pressure ulcers. There were good systems of governance at board and at ward level to check patients were receiving the right care and treatment at the right time. Senior and middle managers, as well as ward staff were committed to these systems.

We followed the care and treatment pathway of 20 people across eight wards that included surgical, medical and the emergency department.

We found that the trust reported incidents of pressure ulcers and learned from adverse events in order to improve patient safety. There were standard procedures and treatment protocols in place and staff knew what these were. Care activities for each patient were recorded and monitored to support consistent care.

Patients were assessed to establish the care they needed and care and treatment was planned and delivered in a way that was intended to ensure people’s safety and welfare. Risks of pressure ulcers and risk of poor nutrition were identified and managed. Plans of care and treatment were implemented and reviewed, including when patients transferred between wards and departments. There were systems in place to identify and ensure support at mealtimes for patients at nutritional risk. We found some care records about people's support with nutrition in some wards could be improved.

There was generally good multi-disciplinary team and mult-agency work to treat and support patients and staff had access to appropriate training and specialist nurses. There was appropriate and sufficient specialist equipment to ensure patient's safety and comfort.

People generally made very positive comments about the service including:

'Excellent care- even down to the cleaner'

"They look after him well but he doesn't like the food"

"The nurses have been brilliant"

'Nothing is ever too much trouble for them'

"They've all been polite and involved in his care"

"The staff are good and the food is OK"

People who were receiving the service told us that they were treated with respect and that staff were helpful and informative. They told us that nurses and doctors gave them clear information about their health conditions, what investigations were needed and the treatment they required.

Comments received included:- ''They have been really good. Have kept us informed.''

We observed the activities within the department and noted that people's privacy and dignity was being maintained at all times.

Our rating of services stayed the same. We rated it them as good

For an overview of our findings at this inspection please see overall summary above.