We arrived at Birmingham Children’s Hospital unannounced. The inspection team was led by one of four CQC inspectors and included a pharmacy inspector.

During our inspection we spoke with a total of 20 people who were using the service and families. We also spoke with the staff supporting them. We looked at the care and treatment that people were receiving within: the Emergency Department (A&E), in theatres and on Ward 15 (including the Teenage Cancer Trust Unit).

People told us that they were happy with the care and treatment they received. They told us that they and their families were fully involved in making decisions about treatment and how it was provided. Comments included: “It is the care that is important and we certainly get good care here” and “Good quality of care.”

People told us that they were listened to and treated with respect by staff working at the hospital. They told us that staff were available when they needed them. Comments included: “The staff are brilliant. I want to take them home” and “The staff are very good. I have no concerns.”

The evidence we collected in theatres identified some minor concerns about the risks relating to how staff were supported in this area. We have issued a compliance action to ensure the improvements to support for staff are made.

We reviewed all the information we held about this hospital and we looked at the information the trust published on its website, which included information presented at the monthly meetings of its board of directors.

We asked other organisations about any information they had that indicated whether or not the hospital was compliant with the essential standards. These organisations were:

• Monitor, the independent regulator of NHS foundation trusts;

• NHS West Midlands, the local strategic health authority;

• Heart of Birmingham (teaching) PCT, the lead commissioner of the service;

• Birmingham Safeguarding Children Board

We received positive information about the hospital from these organisations.

We asked the hospital’s managers for information that showed us how the hospital met five of the essential standards (outcomes 1, 4, 7, 16 and 21) and they sent us comprehensive information within the timescale we set.

We met with the trust on 16 August 2011. At this meeting we discussed the plans for their review.

We carried out an unannounced visit on 14 September 2011 and made arrangements with the trust to return the following day, 15 September 2011. During the visits we visited a variety of outpatient and inpatient areas throughout the hospital. This included the emergency department, theatres, the burns unit, paediatric intensive care and a variety of medical and surgical wards. We talked with the paediatric retrieval team and a variety of key staff responsible for leading the services provided at the hospital.

People who used the service (parents, carers and patients) told us that they were happy with the care they received at the hospital and that their health care needs were being met. They told us that staff explained their care, treatment and support choices to them and that they had the opportunity to be involved in their care. People told us “The staff have been really good. My son had a procedure and the staff explained what they were doing, what the results were and what the next steps were”, “the nurses let me wash my daughter and get her dressed. They give me the option of whether I want to do this” and “I have all the confidence in the world in this place”.

People told us that they were listened to and treated with respect by staff working at the hospital and that staff were available when they needed them. People told us “The nurses encourage what my son feels most comfortable with. They keep my son happy and that is the most important thing”, “there are enough staff. There’s a designated nurse on each shift and other staff know about my daughter and her needs” and “always plenty of staff. Only have to stick head round door and they come.”

Arrangements are in place so that people can continue with their education whilst in hospital. One parent told us “The teacher has been to see my son today. She has done some work with him and has said that she will send it to his school”.

People told us that the hospital was clean and they had no concerns about cleanliness. People told us “The hospital is clean, they are always cleaning”.

We conducted this inspection from the 17-20 May 2016. We returned to the hospital for an unannounced to see the hospital services outside of core business hours.

This is a specialist trust and we made a public commitment to inspect these before June 2016. We held no other intelligence to have raised the risk to require us to inspect before this date.

We conducted this inspection under our comprehensive methodology, giving the trust notice of our inspection. This enabled us to request information prior to the inspection, review information we held about the trust and speak with stakeholders of the trust. We inspected the main site, based in the centre of Birmingham. We also inspected Forward Thinking Birmingham this is a mental health service offered to young people up to the age of 25yrs. The services offered care both in-patients at Parkview and within community hubs.

Please note the service offered under Forward Thinking Birmingham had commenced fully April 2016 just prior to our inspection. BCH (Birmingham Children’s Hospital) is the lead provider of the service delivered by a consortium. The inspection findings are in separate reports.

Please note when we refer to Paediatric intensive care unit (PICU) we are describing to critical care for children and young people.

We rated the hospital ‘outstanding’ overall;

Our key findings were as follows:

• Staff understood how and the importance of raising incidents. Learning was shared amongst the staff group to keep improving quality.The trust had started to report excellence and sharing learning when things when well.

• Multidisciplinary team working was embedded in the trust.We observed this in action.

• The feedback from parents and children was positive, with them reporting they were treated with respect and dignity.Bereaved parents described the compassionate care they received from the staff.

• Results of surgical outcomes demonstrated the team performed better or the same as comparable services.

• We noted how responsive the trust was, for instance, they were piloting a service with the aim to reduce readmissions to the hospital by having health visitors conduct follow-up calls to patients who had been discharged form ED.

• As the trust served patients and parents from outside of the Birmingham environs, parents were able to use nearby accommodation free of charge.This allowed them the opportunity to stay near by their child whilst they were receiving treatment.They were also able to seek support from other families using the accommodation.

• All cancer referrals met the treatment targets, and 100% of all children were seen within six weeks of referral.

• Safer staffing tool demonstrated there was enough nursing staff to meet patients’ needs supplemented by bank staff.Staffing sickness rates were below the England average.

• The trust had a strategy in place to ensure it met its vision. Systems were in place to ensure the board were aware of any risks that could prevent it from meeting the vision.

• Staff were aware of the values and were assessed against them as part of the appraisal process.

• The leadership was well respected amongst the staff group and were effective, with succession planning in place and a board development programme.

• The culture was one of support of each other, staff referred to ‘Team BCH’, and using opportunities to listen to patients carers and visitors.

• Seven never events had occurred in surgery.This had resulted in the theatre team being investigated internally to try to identify a pattern and areas for improvement.The trust had commissioned an external company to help them identify areas of improvement.A theatre task force was in place to drive the momentum.

• There had been outbreaks of reportable infections, and we saw that improvements were needed regarding hand hygiene in neonatal services.However, we did find most areas to be visibly clean.

• Consultant staffing levels in neonatal did not meet the best practice guidelines.There was a vacancy rate of 26% in child and adolescent mental health services (CAMHS).

• We saw there were a lack of up to date care plans in place for (CAMHS) patients and a lack of outcome data for neonatal services.

• PLACE scores returned demonstrated that patients were not fully satisfied with the food.The trust had done work to improve the food with the support of dieticians and the introduced defined meal times.This included feedback place mats and music for example.

• PICANET data (2014) demonstrated that standardised mortality ratios were within expected range.

We saw several areas of outstanding practice including:

• Within medical care, we saw outstanding use of storytelling therapists to help with children’s emotions, anxiety and distress during their stay in hospital, and to help to explain treatment processes to them.Following a session of storytelling therapy, one parent reported their child had not asked for their usual pain relief overnight.

• On the PICU, a safety huddle (a safety briefing meeting) was held three times throughout the day to review patients and the PICU patient flow.An additional safety huddle was held at 4.30pm during the inspection, as patient demand was greater than capacity, which was attended by the Medical Director who was on call that evening.This was outstanding practice with team involvement for safety.

• The trust has implemented a Rare Diseases Strategy, which will deliver an innovative approach for children who due to their rare or undiagnosed condition would be required to attend multiple outpatient appointments with a variety of specialities.The Rare Disease Centre will enable all clinicians involved in the care of the child to be present to provide a holistic approach in one appointment.

• Transition services demonstrated a service which was actively supporting young people to moveinto adult services.Serviceswere offered both in and out of the hospital, and the multidisciplinary team worked in a cohesive fashionsuch as joint clinics.

• End of life core service supported children and young people and their families during palliative care and at the end of their life.Services were responsive, with referrals accepted within 24 hours. Urgent discharges were achieved within 24hrs so children and young people could die where they requested.

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

Importantly, the trust must:

• The trust must take action to ensure that learning from serious incidents involving neonates ward are shared consistently across the trust.

• Review governance processes to ensure neonatal services assess, monitor and mitigate risks to all neonates across the trust. This should include reviewing the neonatal governance structure and morbidity and mortality meetings.

• Radiology must ensure that a radiologist is always available for advice and for protocolling CT and MRI examinations.

• Within CAMHS community, the trust must ensure there are sufficient numbers of skilled and qualified staff to provide an effective service.

Please note more outstanding practice and ‘must’ and ‘should’ actions can be found at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals