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Archived: Abbey Field Medical Centre

Inspection Summary

Overall summary & rating

Updated 5 July 2016

This report describes our findings for the quality of care provided within this core service by One to One (North West) Limited at the Abbey field Medical Centre location. Where relevant we provide detail of each location or area of service visited.

Our judgement was based on a combination of what we found when we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from people who use services, the public and other organisations.

Where applicable, we have reported on each core service provided by One to One (North West) Limited and these are brought together to inform our overall judgement of One to One (North West) Limited.

Our key findings were as follows:

  • Services provided to expectant mothers were not always safe because some policies provided information that did not always provide clear guidance for staff.

  • Incidents were not being reported to CQC under the statutory notifications’ regulation.

  • Mandatory training did not include training in the management of high risk situations, for example managing patients who had previously had caesarean sections and opted for home birth.

  • Care had not been adequately risk assessed or documented in the patients’ notes. We could not be assured that women assessed as requiring medical intervention or assessment were seen by a medical practitioner.

  • Training of staff in safeguarding children at level three at 71%, was not sufficient, and we found evidence that required safeguarding referrals had not been made.

  • However we also found that the ethos of One to One (North West) Limited to be good for supporting women who have a low risk pregnancy.

  • Policies for low risk births followed national guidance. However, policies did not always follow national guidance in respect of high risk births.

  • Pain relief for women at home was limited, and stronger pain relief would require hospital admission. We were not assured that women were advised of this prior to booking with the service.

  • The service was effective at encouraging women to breast feed their babies, achieving higher than the national average breast feeding rates.

  • Outcomes were generally positive for women but the service did not collect data consistently to improve services and identify trends.

  • Multidisciplinary working was variable. The provider and the clinical commissioning groups were working to resolve contracting issues. However communication with local hospitals was not sufficient.

  • Hand held records were not always contemporaneous or as detailed as required.

  • Consent was not always fully recorded in line with national guidance.

  • Mental health issues were not always addressed in accordance with national guidance.

  • A governance system was in place but that this did not always provide consistent information for the senior team.

  • Women were generally satisfied with the service and would recommend it to their family and friends.

    We saw several areas of poor practice where the provider needs to make improvements.

    Importantly, the provider must:

  • Ensure that serious untoward incidents are captured, documented, robustly investigated and where required reported to the CQC under the statutory notification regulations.

  • Review the risk management practices and supporting documentation to ensure these accurately reflect evidence based practice and provide unambiguous guidance to staff.

  • Ensure that women in their care are robustly risk assessed at booking also at each contact and an accurate record is made of risk assessments to determine if One to One (North West) Limited can meet or continue to their needs.

  • For women who require referrals to specialist obstetric and or hospital led care, One to One (North West) Limited must ensure that timely referrals are made and accurately documented to ensure that women are protected from the risks of inappropriate care.

  • Ensure that women in their care have access to obstetric referral within the locality they intend to give birth.

  • Ensure that staff employed by One to One (North West) Limited follows evidenced based practice including best practice guidance contained within their own policies and supporting documentation.

  • Ensure that staff make accurate records of information given and or discussed with women about risks and benefits associated with a chosen birth option to ensure they have sufficiently detailed information about the risks to enable them to make informed choices and or consent to treatment.

  • Ensure that there are contracts and service level agreements in place between One to One Midwives (Northwest) Limited and all commissioners, community and acute providers in Essex to ensure that women receive appropriate care.

  • Ensure that all acute hospitals are notified about women in their locality who are booked with One to One Midwives (Northwest) Limited.

In addition the provider should:

  • Consider review of risk management documentation to provide streamlined, clear and up to date guidance for staff on how One to One (North West) Limited expects staff to manage risks.

  • Review the audit processes for the service to ensure that all outcomes to demonstrate safe maternity care are provided.

  • Look at the staff contracts, job descriptions and working hours to ensure these comply with the European Working Time Directive.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas


Updated 5 July 2016


Updated 5 July 2016


Updated 5 July 2016


Updated 5 July 2016


Updated 5 July 2016

Checks on specific services


Updated 12 April 2017

  • Training records showed only 33% of maternity assistants (MAMAs) were compliant with their mandatory training requirements.
  • There were no audits carried out to check the cleanliness of the environment or hand hygiene.
  • A birthing pool audit had been carried out; however, this did not cover visual inspection of the pools or whether midwives were cleaning the pools correctly.
  • No record of cleaning was maintained for the medicines fridge nor the fridge used to store placentas.
  • Midwives were not transporting Entonox (Nitrous Oxide) securely in their cars during transport. This was not compliant with national safety recommendations.
  • There was no system in place to track what visits each member of staff had planned for the day. Our concerns were heightened given there was no local manager in post. This meant there was no record of where lone workers were at any time, and no one had oversight of staff whereabouts.
  • The provider was not registered to supply and administer controlled medicines (such as pethidine), however, two midwives told us that they administered and disposed of Pethidine for homebirth women, because the local GP prescribes the medicine for the women as required. There was no record of Pethidine waste kept. Whilst senior managers told us that this practice was not in line with the provider’s protocol, we however saw that the ‘Medicine’s management’ policy in place did not make this clear.
  • Midwives were inconsistent in the medicines they offered women for the management of the third stage of labour. We also found the provider’s “Management of the third stage of labour” policy did not reflect evidence-based practice in relation to these medicines.
  • Women and babies electronic and paper healthcare records did not reflect one another, often containing conflicting information in terms or pregnancy risk.
  • Although women were on the correct pathway for their pregnancy in correlation with risk, we saw that the pathway title, such as low or high risk, where often missing or incorrect from their records.
  • Of the healthcare records we checked, we saw that there was no paper record of postnatal care for women and babies. However, the provider had recently introduced new paperwork to ensure this. Although because this system was new we were unable to check if these paper postnatal records were being completed.
  • Maternal Early Obstetric Warning (MEOWS) charts were not in use and scores were not calculated.
  • Where care had deviated from evidence-based practice recommendations, such as if a vaginal examination was not performed in labour, we saw that the reasons for this were not recorded in women’s healthcare records.
  • Staff did not have regular one-to-one meetings with a manager.
  • Staff did not demonstrate they understood the Fraser guidelines sufficiently.
  • Midwives had not received additional training in complex conditions in pregnancy, such as diabetes.
  • Of the twelve midwives employed in the Essex area, seven midwives were newly qualified or had been qualified for approximately a year. There was also no clinical manager for the area. This meant that the majority of staff were junior without adequate local supervision in terms of management.
  • The service had not carried out a needs assessment of the local community it provided a service to.
  • There had not been a registered manager in post since July 2015. There had also been no clinical manager based at the Essex service since November 2016 since the previous manager resigned from their post. This meant that 12 midwives, three midwifery support assistants (MAMAs) and an operations manager worked without clinical management presence. Staff told us that there was one clinical manager in the North West location; who line managed them and was accessible via telephone as required. However two senior managers also confirmed that this clinical manager only visited the Essex service bi-monthly.
  • The provider’s risk register did not mention who was accountable for each presented risk, and correlating action plans to the risk register were not updated following risk register review.