Birmingham Women's and Children's NHS Foundation Trust

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

There was evidence that safety had improved at Parkview. There were systems in place to feedback learning, and improvements were made as a result to reduce risk of harm to children and young people. Staff liaised with other professionals involved in children’s and young people’s care and worked with other teams to ensure care was delivered in a safe way. Children and young people said they felt safe, and their concerns were taken seriously. Staff understood safeguarding and there were effective systems in place to ensure children and young people were protected from abuse. Staff assessed children’s and young people’s individual risks and involved them in this. Staff knew how to manage children and young people’s risks. The environment was mostly designed to keep children and young people safe and meet their needs. However, children and young people’s relatives said, and we saw, that the edges of furniture could be a risk to children and young people. We saw this risk was assessed for individual’s where appropriate in their care plans and risk assessments. There were appropriate staffing levels and skill mix to ensure children and young people received consistently safe care that met their needs. The trust trained staff to deliver safe care, however, they had not trained sufficient staff in Immediate Life Support. The trust had identified this and taken action to reduce this risk. The environment was clean and hygienic to ensure children and young people were protected from the risk of infection. Children and young people were involved in decisions about their medicines. Their medicines were stored safely and there were appropriate arrangements for the management of Controlled Drugs. We found a couple of errors in medicine records however when we raised these with managers, they took immediate action to reduce risks.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Children and young people told us that action was taken when they were involved in an incident. Records showed that where a young person was involved in an incident their parent was informed of this and the action taken to reduce the risk of it happening again.

One staff member told us that learning was not fed back formally. However, another staff member said learning was fed back through supervision & clinical governance meetings. Managers told us they had launched the lessons learnt framework 2 weeks before we visited. This included weekly improvement huddles where learning from incidents was discussed. Managers told us lessons learned were discussed at the morning operational meetings where incidents were discussed. They said learning identified in these meetings was fed back in handovers. Managers also told us about incidents involving medicines where there had been gaps in recording of administration. This was handed over to the nursing team. A ‘table top’ review of medicines incidents had been performed in the month before & the findings of this was that nurses were disturbed too much during medicine rounds. The learning from this was that nurses would now wear a red arm band or tabbard to signify they were doing the medicine round. There was also a sign on the clinic room door to alert people that the medicine round was in progress so as not to disturb and distract the nurses. Managers provided evidence that they had learned from medicine errors & gaps found in children & young people’s observation records. We saw the learning from where children’s & young people's observations had not always been completed or recorded. The ‘Safe & Supportive Observations policy’ had been recently reviewed & updated. The multidisciplinary team were responsible for ensuring observations were clearly documented & discussed in handovers. The observations record sheet was updated so there was space to record. The Matron & Governance Lead do spot checks & audits to ensure the learning had been embedded in staff daily practice. Managers showed us they had shared lessons learned, from their audits on children & young people’s risk assessments, with staff. This included a reminder to all staff to update risk assessments & care plans.

Young people told us they had more care reviews with the multidisciplinary team than previously as they were near to 18 years so transferring to adult mental health services. They said this included their community mental health and had helped them to prepare for the transition.

Staff told us there were handovers between each shift where information was discussed about each person’s needs and risks. We observed a handover which was very detailed, and people’s risks and any safeguarding concerns were discussed. The nurse leading the handover allocated roles to each staff member for the shift. Staff told us they had easy access to an online share point folder. This included information from handovers and people’s care plans and risk assessments. Staff told us how they worked with young people’s community mental health teams to ensure they had the information needed to prepare for the young person being discharged. This included where appropriate the young person’s transition to the adult mental health service.

We attended the monthly quality improvement group meeting with partners where partners challenged and asked Parkview managers to provide evidence of improvements. Partners told us they could see improvements were being made and had renewed confidence in the service. Partners expected the service to ensure there were smooth pathways and that children and young people were safely discharged or moved on to other services.

Children and young people told us they felt safe at Parkview. Young people and their parents said that if they raised concerns these were followed up and reported to the local authority safeguarding team when needed. Young people and their relatives said there was a flexible visiting policy, and they were welcome to spend evenings and weekends with their relatives which fitted around their work schedules. Relatives said they could ring the ward at any time and felt there was an open door policy.

Staff said they received level 2 & 3 safeguarding children and adults online training which was updated every 12 months. This is the appropriate level of training in safeguarding for the staff at Parkview. The trust told us that 95% of staff had completed training in safeguarding adults and children from abuse and harm. Staff did not always receive regular supervision in safeguarding. One staff member said they did not have safeguarding supervision and was not aware this was available. However, another staff member said they had safeguarding supervision every month. Staff said audits were completed of safeguarding records to assess the quality of referrals and outcomes. The clinical nurse specialist had oversight of the safeguarding referrals on the ward. Staff said there were plans to have ‘Safeguarding Champions’ on each ward to ensure this was discussed regularly and best practice was shared.

Children and young people told us they were involved in the development of their care plan with their named nurse. They had a weekly multidisciplinary team ward round which they and their relatives were involved in. They also had a Care Programme Approach meeting every 6 weeks. Children and young people told us that staff explained to them clearly the reason for any restrictive interventions. For example, if their leave from the hospital was stopped, staff explained the reasons for this and reviewed the restriction regularly. However, some young people said that some support workers did not always seem to know their individual risks. Records showed that staff were made aware of all young people’s risks and this information was shared in handovers. Children and young people said there were daily community meetings on the ward where they discussed the activities for the day, any risks, and if anything was broken so it could be repaired or replaced. Relatives told us they were involved in their relative's care plans and risk assessments.

Staff told us they involved children and young people in their risk assessments and how they could support the person to reduce the risk to their safety and wellbeing. Staff told us that incidents were managed well at Parkview. They said that staff always reported incidents and risks. Managers ensured that these were reviewed and closed once they had assurance that the risk was managed and reduced.

Children and young people’s records showed that the person and their relatives where appropriate were involved in their risk assessments. Records showed how risks were reviewed with the person and updated as needed. Ashfield ward was closed at the time of our visit and is the only ward that has a seclusion suite. A risk assessment showed how managers were reducing the risks of staff not having the skills to ensure restrictive practices were reduced. This included all support workers, nurses and doctors being trained in the use of seclusion and all staff completing a one-day training course on human rights and restrictive intervention. The Parkview Segregation and Seclusion Policy was ratified at Policy Review Group in March 2024. Managers were liaising with other West Midlands mental health units that operate seclusion suites to ensure best practice was shared.

Children and young people told us about the sensory room on Heathlands ward which they said helped them to feel safe. Children and young people and their relatives said they felt safe. They said they could personalise their bedroom which helped them to feel safe and secure. However, relatives showed us there were no corner guards on bedroom furniture. They said this meant there was a risk when their relative self-harmed. Managers told us this was individually risk assessed and we saw this in records where it stated how staff would manage the risk.

Managers said that following consultation with the trust, funding was agreed to extend the cleaning hours at Parkview for the afternoon and evening. This helped to ensure the environment was well maintained and clean. One staff member on Heathlands ward told us there had been an incident where they had lost their alarm in the ward office, however they obtained a replacement alarm the same day. This was reported as an incident. All staff had an alarm for each shift.

We observed pointed edges on desks in people’s bedrooms which could be a risk to the person. The wards were clean. We saw clean stickers in the clinic rooms which showed that areas and equipment had been cleaned on the day of our visit. In the clinic room on Heathlands ward we saw that the weighing scales were last calibrated in March 2020. Managers had identified this, and provided evidence which showed that the external contractors had already been requested to come and re-calibrate these scales, which took place the following week after the visit. Some equipment such as containers for blood tests, swabs, dressings, COVID-19 tests, 1 drug screening kit and a box of hyper dermic syringes had expired. Staff removed these at the time and new stock was ordered where needed. We saw that the clinic room on Irwin ward was cramped. Staff said they give people naso gastric feeds in the clinic room if it is safe to do so. However, they can use the group rooms for this if more staff support is needed. We saw that staff checked the emergency life support equipment on each ward and this was all available and in date to use if needed.

Community meeting minutes showed on 7 March 2024 that people said the showers were cold on Sundays. People said this again on 19 April 2024 but there was no evidence of action taken. The environmental risk assessment on Heathlands ward stated as a red risk that various corners and surfaces on the ward could cause harm when a person self-harmed through banging their head. The control was for staff to follow the policy on self-harm in relation to head tapping/banging. We looked at this policy however, it did not include reference to making adaptations to the furniture to reduce the risk of harm. Managers told us this was individually risk assessed and we saw this in records where it stated how staff would manage the risk. Records showed that staff checked equipment used for physical health checks, and this was calibrated to ensure it was accurate. The trust showed us evidence that engineers regularly tested the water to ensure it was safe to use and free from legionella. The environmental risk assessment for Irwin ward showed that additional alarms had been provided for staff. A new process for temporary staff was in place and lockers had been provided in the main reception. Each locker contained a belt, pouch, keys, and alarm and these were signed out / in each day by security staff. Security staff were now available in reception 24/7 and closed-circuit television cameras (CCTV) had been installed, and the number of cameras is set to be increased to make the environment and surrounding area safer. We reviewed the ligature risk assessments for Heathlands and Irwin wards. These were dated 11/4/24. They showed risks were reduced where needed and included references for staff to ensure individual risk assessments were in place where appropriate.

Children and young people and their relatives gave us mixed feedback about staffing. Children and young people told us there were not always enough staff which meant they could not always go out on leave or to school. On Heathlands ward children and young people said that most days there were some non-permanent staff and 2 times a week there were not enough staff. One young person said staff were approachable and friendly. However, another young person said some staff did not support so well at mealtimes and sat in silence, although regular staff were more chatty and helpful. Relatives said most supportive staff at Parkview compared to previous hospitals. They said staff cared and went out of their way to help and make relatives feel welcome. They said staff took time to get young person to trust them and built positive relationships. Relatives said staff were mostly regular staff and fewer bank and agency staff than previously. A relative told us that staff were good at explaining things to their relative. However, one relative said some staff didn’t know how to respond to a young person when they self-harmed which made the situation worse. Another relative said staff often forgot their relative’s observation levels which was ‘irritating but also risky’.

Agency usage for April 2024 was 4% for registered nurses & 3% for support workers. Bank staffing included substantive staff working bank & was at 33% for registered nurses & 21% for support workers. There was 1 consultant psychiatrist vacancy. The trust was recruiting a locum to cover this. As the 3 wards were not open the provider was over-recruited for registered nurses. The trust did this to facilitate resilience & support to staff as part of the improvement plan. The trust was recruiting to 12 support worker vacancies. They had increased the housekeeper posts & funded an additional 2 posts for Heathlands & Ashfield wards. The service had submitted a bid for charities monies to fund additional posts, activity coordinator and personal trainer, to support young people's recovery. Most staff said they had monthly management supervision & had clinical supervision which they found useful. Staff said they received an induction which was good & helped prepare them for their job role. Staff said they received training in ‘Attachment and Development Trauma’, autism, eating disorders, Dialectal Behaviour Therapy (DBT), & risk management to help them meet people's needs. Some staff on Heathlands ward said they had not received Nonviolent Crisis Prevention and Intervention (CPI) training. Managers told us that they were training more staff to become trainers in this so all staff could be trained. Staff said they could attend specialist training & were encouraged to attend conferences to support their development. Staff said staffing had improved which meant they were now able to do their job roles & there were now more permanent staff. They said a year ago there was a reliance on temporary staffing, but this had now changed. Staff said the handovers between the shifts gave them enough information to know how to support children and young people. The trust had recruited Internationally Educated Nurses and showed us the full induction programme which included mentoring.

Not all staff received regular supervision. Supervision records for April 2024 showed ward managers and clinical nurse specialists, psychologists and occupational therapists were at 100% compliance. However, improvement was needed for nursing staff.. On Heathlands ward compliance was 75% however for Irwin ward it was 35%. Managers identified this was due to change of staffing and improvements were being made. The trust target for sickness absence was 4.75%. The sickness rate at Parkview had decreased from 9.37 % in March 2023 to 4.66% in March 2024 which was lower than the trust target. Staff received an annual appraisal and at time of assessment 97% of staff had an appraisal. The trust trained staff in basic life support, 98% of staff had completed the theory and 80% had completed the practical training. The trust said training in immediate life support was as low as 30% for registered nurses at May 2024 due to new staff being employed. However, all registered nurses were booked to attend this during the next 3 months. The trust had mitigations in place to ensure there were trained registered nurses throughout the 24 hour period. Trained staff were identified through daily operational meetings to ensure these staff were alerted via the paging system. The trust was pursuing if additional courses could be provided to further accelerate the pace of more staff being trained. The trust ensured staff who administered naso gastric feeds to people completed a detailed competency assessment. Staff rotas for Irwin ward April 2024 showed assessed safe staffing levels were met. Where needed, bank staff were employed, who were mostly the trusts permanent staff working extra hours as bank. This meant registered nurses supported new starters who were supernumerary to bolster the ward skill mix and facilitate teaching. Regular bank staff who were familiar with the ward covered short-term sickness. There were several new starters on Irwin ward so bank staffing would be reduced.

Staff said they had access to protective personal equipment. They said they had training in infection control and food hygiene. Records showed that 99% of staff had completed training in infection prevention and control. Managers said that cleaning hours had been increased 7 days a week since March 2024. They had now received funding and were recruiting a housekeeper for each of the 3 wards.

We saw that the wards were clean and tidy. Hand gel was available on entrance to and around the wards and we observed staff using this. The infection control audit for Heathlands ward in January 2024 scored 91% and was rated Good. Some areas were noted to be dusty and cluttered, and an action plan was in place to ensure improvement. The infection control audit for Irwin ward in February 2024 scored 94% and was rated Good. Some areas were dusty, and action was taken to clear rooms of clutter.

Medicine charts contained information about the young person including allergies and Mental Health Act status. This included the young person’s consent to treatment status, and these were completed correctly. We saw that staff had tested the temperature of the fridge where medicines were stored, and these were within the safe storage range. The medicines stored there were in date. We saw the temperature of the clinic rooms where medicines were stored were in the safe range. Staff wore red tabards when administering people’s medicines to show they were not to be disturbed.

Medicine records on Heathlands ward were not always accurate. We reviewed 3 people’s medicine administration records on Heathlands ward. One person’s records included a signature from staff to say they had administered a medicine to the young person on 25/4/24 – this was the day after our visit on 24/4/24. Another young person’s records showed omissions on two days (18 & 19 April 2024) in staff signing to say they had administered the medicines. Staff had not entered a code to state why they had not given the medicine. We raised these issues with staff and managers at time of our visit. Managers provided us with evidence that these issues had been addressed and action was taken to reduce further errors. Medicine records contained information about the young person including allergies and their Mental Health Act status. People’s medicines were reviewed weekly during their ward rounds. Pharmacists visited the ward weekly. Staff said and records showed that this had helped to improve the management of controlled drugs and consent to treatment records. Lessons learned from medicine incident reporting and medicine safety audits were fed back to staff in March 2024. Actions included a new medicines cupboard ordered for Heathlands ward which included a controlled drug cabinet. The feedback showed learning and action taken in an easy-to-read format, so it was clear to see.