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Birmingham Women's Hospital

Provider Birmingham Women's NHS Foundation Trust Type NHS Healthcare Organisation Region West Midlands Last inspected 13 Apr 2016

Overall rating: Requires Improvement  View full CQC report

Domain ratings

Five CQC key questions
Safe
Good
Effective
Requires Improvement
Caring
Good
Responsive
Requires Improvement
Well-led
Requires Improvement

Earlier inspection findings

pre-2024 framework · 19 must-do 17 should-do

Must-do actions (19)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 19
Must do
Safe
Healthy Start vitamins must be stored securely in all community maternity team offices.
Regulation: Regulation 12 (Safe care and treatment)
⚠ Medicines including intravenous fluids were not stored securely.
Must-do action 2 of 19
Must do
Safe
Medicines are prescribed and stored in line with the trust policy, particularly intravenous fluids.
Regulation: Regulation 12 (Safe care and treatment)
⚠ Medicines including intravenous fluids were not stored securely.
Must-do action 3 of 19
Must do
Safe
All community midwives must attend safeguarding supervision in line with Department of Health requirements (Working Together to Safeguard Children, 2015).
Regulation: Regulation 17 (Good governance)
⚠ We were not assured the staff understood or knew about the function of safeguarding supervision and their requirement to attend for ongoing support with safeguarding.
Must-do action 4 of 19
Must do
Safe
Improve the application of infection prevention and control procedures in relation to the use of personal protective clothing and equipment and hand hygiene.
Regulation: Regulation 12 (Safe care and treatment)
⚠ Staff were not consistently adhering to infection prevention and control procedures in relation to the use of personal protective clothing and equipment and hand hygiene.
Must-do action 5 of 19
Must do
Safe
Properly maintain all equipment and medical devices.
Regulation: Regulation 12 (Safe care and treatment)
⚠ Equipment such as beds and infusion pumps had not been subject to regular servicing and electrical safety checks.
Must-do action 6 of 19
Must do
Safe
Provide secure storage for patient records across all clinical areas.
Regulation: Regulation 17 (Good governance)
⚠ Medical records were stored in notes trolleys and storage units on the ward areas but although they were kept away from the public areas they were not secured. We noted there were some occasions when the area was unstaffed and therefore could have been accessed by unauthorised persons. Care records …
Must-do action 7 of 19
Must do
Responsive
Ensure the project to develop a second emergency theatre team is progressed in a timely manner.
Regulation: Regulation 17 (Good governance)
⚠ Issues with the time taken to assemble the on-call team had been identified on the risk register for over five years. During this time audits had been completed and the case made for a second resident team, however, the divisional leadership team had been unable to secure an agreed date …
Must-do action 8 of 19
Must do
Well-led
The trust must ensure all HSA1 certificates for termination of pregnancy are fully completed by the registered medical practitioners signing them.
Regulation: Regulation 17 (Good governance)
⚠ There was a systemic failure by the registered medical practitioners (RMP) to clearly indicate on some HSA1 certificates if the patient had been ‘seen/treated’ by either of the two RMPs who signed the certificate. This was because a section of the form had not been properly completed. This meant the …
Must-do action 9 of 19
Must do
Well-led
Identify, monitor and mitigate all risks relating to developing the complex abortion service pathway. In particular, in respect of processes required and the impact on staff and patients of distressing elements of late gestation termination.
Regulation: Regulation 17 (Good governance)
⚠ The trust had not identified, monitored and mitigated some risks relating to developing the complex abortion service pathway. In particular in respect of processes required, the need to provide training to staff because of the impact on staff and patients of foetus showing signs of life in late gestation medical …
Must-do action 10 of 19
Must do
Safe
Provide training to ward staff caring for complex abortion services patients in the appropriate procedures for responding to late gestation termination of pregnancy where the foetus may be indicating signs of life.
Regulation: Regulation 17 (Good governance)
⚠ The trust had not identified, monitored and mitigated some risks relating to developing the complex abortion service pathway. In particular in respect of processes required, the need to provide training to staff because of the impact on staff and patients of foetus showing signs of life in late gestation medical …
Must-do action 11 of 19
Must do
Safe
Ensure teamwork between the complex abortion care service, ward teams and bereavement team and wider medical teams are strengthened to mitigate risks involved in late gestation termination of pregnancy.
Regulation: Regulation 17 (Good governance)
⚠ The root cause analysis of an incident that led to a serious case review underway at the time of our inspection indicated differently. It identified teamwork between the abortion care service, ward team and bereavement team and wider medical team needed to be strengthened.
Must-do action 12 of 19
Must do
Effective
Take steps to ensure multi-disciplinary teamwork is improved where clinicians from other trusts are contributing the care of patients.
Regulation: Regulation 17 (Good governance)
⚠ The fact that some members of the multi-disciplinary team were not directly employed by the trust reduced flexibility and affected the timely access to some aspects of care.
Must-do action 13 of 19
Must do
Caring
Clarify the method clinician’s should use to establish consent to termination of pregnancy from adult patients with learning disabilities.
Regulation: Regulation 11 (Need for consent)
⚠ The service had no established pathway in place for addressing consent to treatment for women with a learning disability.
Must-do action 14 of 19
Must do
Effective
Ensure that the data collected for the Neonatal Audit Programme (NNAP) reflects the care given within the unit.
Regulation: Regulation 17 (Good governance)
⚠ The unit did not meet the Neonatal Audit Programme (NNAP) standards due to inconsistent data entry.
Must-do action 15 of 19
Must do
Effective
Ensure staff receive mental capacity training in line with trust guidance.
Regulation: Regulation 11 (Need for consent)
⚠ The service had no established pathway in place for addressing consent to treatment for women with a learning disability.
Must-do action 16 of 19
Must do
Responsive
Implement a system to assess, monitor and improve the waiting times across clinics in the outpatients and diagnostic departments.
Regulation: Regulation 17 (Good governance)
⚠ The trust had not identified, monitored and mitigated some risks relating to the long waiting times across clinics in the outpatients and diagnostics department. In particular, in respect of the antenatal clinic the long waiting times was not on the risk register by not being regularly reviewed, and did not …
Must-do action 17 of 19
Must do
Well-led
Mitigate the risks relating to the health, safety and welfare of service users by regularly reviewing the risk register and include a timescale in completing any risks identified.
Regulation: Regulation 17 (Good governance)
⚠ The trust had not identified, monitored and mitigated some risks relating to the long waiting times across clinics in the outpatients and diagnostics department. In particular, in respect of the antenatal clinic the long waiting times was not on the risk register by not being regularly reviewed, and did not …
Must-do action 18 of 19
Must do
Responsive
Reduce the waiting times in diagnostics department
Regulation: Regulation 17 (Good governance)
⚠ The trust had not identified, monitored and mitigated some risks relating to the long waiting times across clinics in the outpatients and diagnostics department. In particular, in respect of the antenatal clinic the long waiting times was not on the risk register by not being regularly reviewed, and did not …
Must-do action 19 of 19
Must do
Safe
Ensure old diaries used by community midwives are securely stored.
Regulation: Regulation 17 (Good governance)
⚠ Old diaries were securely stored at some of the bases ie Charlotte Road and Quinton Lane but not at other community midwifery bases. Community midwives did not routinely send old diaries to the hospital site for storage.

Should-do actions (17)

Recommended improvements to enhance service quality.

Should-do action 1 of 17
Should do
Well-led
Review community midwives’ caseloads to ensure equitable distribution of numbers and complexity pending review of staffing planned for June 2016.
Should-do action 2 of 17
Should do
Caring
Review how patients are informed about and supported to clearly understand the process and all potential clinical elements of late gestation termination of pregnancy.
Should-do action 3 of 17
Should do
Responsive
Develop and put in place agreed aftercare pathways for ward staff to follow to best support patients. These should address the needs of patients where they may differ in respect of the decision to terminate their pregnancy.
Should-do action 4 of 17
Should do
Safe
Review the procedures for pre-operative fasting to ensure food and fluids are withdrawn for the minimum length of time to ensure the safety of patients and the maintenance of hydration.
Should-do action 5 of 17
Should do
Effective
Ensure where best interest decisions are made on behalf of a patient that reasons for the decision and other options considered, are clearly recorded.
Should-do action 6 of 17
Should do
Responsive
Review the application of its policy for the use of interpreters to ensure all patients who require an interpreter are offered an independent interpreter.
Should-do action 7 of 17
Should do
Well-led
Ensure there are processes in place to ensure learning is shared between different parts of the service and there is improved communication across services to enable the development of best practice.
Should-do action 8 of 17
Should do
Safe
Review the process for escalation of clinical concerns to ensure a timely response is achieved.
Should-do action 9 of 17
Should do
Well-led
Introduce measures to reduce or remove risks on the risk register within a timescale that reflects the level of risk and impact on people using the service.
Should-do action 10 of 17
Should do
Effective
Take steps to improve the accessibility and reliability of the electronic care planning system in place in gynaecology.
Should-do action 11 of 17
Should do
Well-led
Consider the perception that gynaecology is not dealt with equitably and issues prioritised in the same way as for other services and take steps to ensure equity.
Should-do action 12 of 17
Should do
Safe
MEWS charts are completed appropriately.
Should-do action 13 of 17
Should do
Responsive
Patients undergoing induction of labour are supported to continue the induction process within a satisfactory timeframe.
Should-do action 14 of 17
Should do
Safe
On-site consultant hours reflect the recommendations by the RCOG in relation to the number of births.
Should-do action 15 of 17
Should do
Well-led
Use the capacity data captured to influence staffing levels and business plans.
Should-do action 16 of 17
Should do
Caring
Consider it provides the persons with the information they would reasonably need by giving patients leaflets about their post treatment, rather than being directed to go on to the website.
Should-do action 17 of 17
Should do
Responsive
Consider it has a consistent system across all departments to flag up any learning disability patients.

Location details

CQC ID: RLU01
Local authority: Birmingham
Region: West Midlands

Inspection report

Type: Comprehensive inspection
Date: 13 April 2016
Rating: Requires improvement
Actions: 19 must-do 17 should-do
AI-extracted 3 Jun 2026