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Birmingham Children's Hospital

Type NHS Healthcare Organisation Region West Midlands Last inspected 14 Jun 2024

Overall rating: Good  View full CQC report

Domain ratings

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

Earlier inspection findings

pre-2024 framework · 8 must-do 12 should-do

Must-do actions (8)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 8
Must do
Safe
The trust must ensure controlled drug records are accurately documented as set out in the Misuse of Drugs regulations 2001 and amendments and there are suitable and safe storage arrangements available for all medicines.
Regulation: Regulation 12(1)(2)(e)(g): Safe care and treatment
⚠ Controlled drug recording did not always follow the Misuse of Drugs regulations 2001. We observed some drawers used for medicine storage were overfilled. This meant medicine containers became damaged by the drawer above, and therefore some medicine identification information was missing.
Must-do action 2 of 8
Must do
Safe
The trust must ensure patients have timely access to mental health services.
Regulation: Regulation 12(1)(2)(a)(b): Safe care and treatment
⚠ There was limited provision for specialist mental health assessment for patients presenting with acute mental health needs. The service did not have 24-hour access to mental health liaison and specialist mental health support. The time to be seen by a CAMHS professional ranged from 292 minutes to 1,208 minutes. The …
Must-do action 3 of 8
Must do
Safe
The trust must ensure there is a suitable mental health room including toilet facilities which complies with statutory requirement.
Regulation: Regulation 15(1)(c): Premises and equipment
⚠ Patients presenting with acute mental health concerns did not have access to a dedicated room which met national guidance relating to the provision of a safe environment. There was no mental health assessment room. There was only 1 toilet to serve the whole of majors and minors. It had several …
Must-do action 4 of 8
Must do
Well-led
The trust must have systems and processes in place to enable staff carry out regular audits, such as sepsis audits in order to monitor and improve patient safety.
Regulation: Regulation 17(1): Good governance
⚠ Compliance with sepsis screening and treatment was not routinely audited. This meant there were missed opportunities to identify non-compliance and share learning with staff to improve practice and safeguard patients from ongoing risk of harm. The lack of auditing of sepsis by the service suggested a lack of oversight and …
Must-do action 5 of 8
Must do
Safe
The trust must ensure all staff complete mandatory training, including but not limited to safeguarding, learning disability and Mental Capacity Act training.
Regulation: Regulation 18(2)(a): Staffing
⚠ The service provided mandatory training in key skills but not all staff completed it. The service did not provide training to care for patients with complex needs. Not all staff had training on how to recognise and report abuse. Not all staff had received training in consent, Mental Capacity Act …
Must-do action 6 of 8
Must do
Safe
The trust must ensure all relevant medical and nursing staff are trained to the required level of life support for the care and treatment they are delivering. This includes ensuring there is always a nurse in charge with this training on duty in line with the Royal College of Nursing safestaffing guidelines.
Regulation: Regulation 18(1)(2)(c): Staffing
⚠ Not all relevant staff were trained to the appropriate level of life support training. Compliance to the highest level of life support training was not achieved for medical or nursing staff. Data also showed RNs undertaking nurse in charge duties had not all completed APLS training.
Must-do action 7 of 8
Must do
Effective
The trust must ensure staff are provided with training in the Mental Health Act and staff understand the code of practice.
Regulation: Regulation 18(1)(a): Staffing
⚠ Not all staff knew how to protect the rights of patients subject to the Mental Health Act 1983. Not all staff understood their responsibilities in managing patients experiencing mental ill health. Staff had not received training and not all staff understood their responsibilities of holding patients in the department. This …
Must-do action 8 of 8
Must do
Safe
The trust must ensure staff receive relevant training for restrictive intervention, such as management of actual and potential aggression as per National Institute for Health and Care Excellence guidance.
Regulation: Regulation 18(1)(a): Staffing
⚠ Staff were not trained in restrictive interventions but were required to restrain patients when delivering rapid tranquilisation.

Should-do actions (12)

Recommended improvements to enhance service quality.

Should-do action 1 of 12
Should do
Safe
The trust should ensure staff follow infection, prevention and control processes. This includes but is not limited to consistently embedding trust hygiene and cleanliness standards and ensuring standards for managing peripheral venous and central venous catheters are met to reduce the risk of infection.
Regulation: Regulation 12.
Should-do action 2 of 12
Should do
Safe
The trust should ensure there is always appropriate sight and supervision of patients in the emergency department and waiting areas.
Regulation: Regulation 12.
Should-do action 3 of 12
Should do
Safe
The trust should ensure staff fully implement trust policies and procedures when undertaking enhanced supervision of patients at risk of self-harm.
Regulation: Regulation 12.
Should-do action 4 of 12
Should do
Safe
The trust should ensure all guidance in relation to medicines management that is available to staff is always up to date to ensure national guidance is followed.
Regulation: Regulation 12.
Should-do action 5 of 12
Should do
Safe
The trust should ensure safety checks of emergency equipment including but not limited to defibrillators are checked to ensure they are working and safe to use in line with trust policy.
Regulation: Regulation 15.
Should-do action 6 of 12
Should do
Responsive
The trust should ensure wheelchairs are available for patients to use if required.
Regulation: Regulation 15.
Should-do action 7 of 12
Should do
Well-led
The trust should ensure intravenous guidance in resus area is up to date.
Regulation: Regulation 17.
Should-do action 8 of 12
Should do
Responsive
The trust should consider effective pathways are fully embedded between the Child and Adolescent Mental Health Service (CAMHS) and the emergency department. Where the CAMHS team do not respond within agreed timescales, the service should ensure staff are escalating these concerns so that patients receive care and treatment in a timely manner.
Regulation: Regulation 17.
Should-do action 9 of 12
Should do
Well-led
The trust should ensure that records are accessible to both emergency department staff and the mental health team.
Regulation: Regulation 17.
Should-do action 10 of 12
Should do
Safe
The trust should ensure there are enough suitably qualified staff across all clinical areas, to make sure the service can meet people's care and treatment needs. This includes medical, registered nursing and non-registered nursing staff.
Regulation: Regulation 18.
Should-do action 11 of 12
Should do
Responsive
The trust should consider having play areas for children with complex needs.
Should-do action 12 of 12
Should do
Safe
The trust should consider implementing a process to monitor the use of sedation or rapid tranquilisation, to be assured that administration is in line with policy, not excessive and appropriate.

Location details

CQC ID: RQ301
Local authority: Birmingham
Region: West Midlands

Inspection report

Type: Location
Date: 14 June 2024
Rating: Requires Improvement
Actions: 8 must-do 12 should-do
AI-extracted 2 Jun 2026