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Bradford Royal Infirmary Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 9 April 2020

Our rating of the hospital stayed the same. We rated it as requires improvement because:

  • We rated effective and well led as requires improvement. We rated safe, caring, and responsive as good.
  • At this inspection we inspected four of the core services. We rated three of the services as good, and one as requires improvement. In rating the trust, we took into account the current ratings of the other services not inspected this time.

Are services safe?

Our rating of safe improved. We rated it as good because;

  • Services provided mandatory training in key skills to all staff and made sure most staff completed it. Compliance with mandatory training had improved since our previous inspection.
  • Staff understood how to protect patients from abuse and services generally worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it. Safeguarding training levels had improved since the previous inspection.
  • In children and young people’s services, there were enough nursing staff with the right qualifications, skills, training and experience to keep children, young people and their families safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank and agency staff a full induction.
  • In maternity the service had enough staff with the right qualifications, skills, training and experience to keep women and babies safe from avoidable harm and to provide the right care and treatment. Caseloads among community midwives were within national guidelines and modified to account for the complexity of cases.
  • Services managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned teams. When things went wrong, staff apologised and gave patients and their families honest information and suitable support. Managers ensured that actions from patient safety alerts were implemented and monitored.
  • Staff completed and updated risk assessments for patients and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration. The trust had appointed a sepsis nurse in October 2018 who had rolled out a series of improvements. This included staff training, developing standard protocols and the establishment of a deteriorating patient group.
  • Managers ensured that actions from patient safety alerts were monitored and implemented. Services used monitoring results well to improve safety. Staff collected safety information and shared it with staff, patients and visitors.
  • Services used systems and processes to safely prescribe, administer, record and store medicines. staff followed current national practice to administer and check patients had the correct medicines. The prescribing of oxygen had improved since our last inspection.
  • Most records were clear, up-to-date, stored securely and easily available to all staff providing care. Services used an electronic record system and all staff received full training on use of the system including bank and agency staff.
  • The design, maintenance and use of facilities, premises and equipment mostly kept people safe.

However:

  • Some services did not always manage infection prevention and control well. Ventilation equipment in maternity theatres did not adhere to national guidance, the service did not monitor or control infection risks in theatres consistently well. Compliance with infection prevention and control training in medicine for the period April 2018 to March 2019, was 74.3% for nursing staff and 70.8% for medical staff at this hospital. This did not meet the trust target of 85%. Infection rates on the neonatal unit had increased over the last two years. In the outpatients department we had concerns about the traceability of nasal endoscopes. Audit data indicated 65% compliance with completion of daily cleaning checklists and we saw some apparent gaps in cleaning records.
  • The percentage of women who received one to one care in labour was poor. From November 2018 to October 2019 an average of 70% of women in established labour received one-to-one care. This varied from 57.2% to 82.5% over the period. This had been a concern at our last inspection.
  • There were not always enough nursing staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment in medicine. Nurse staffing on the neonatal unit was not meeting national standards. Only 48.6% of shifts from September 2018 to October 2019 were compliant with national standards.
  • Consultant cover on the neonatal unit was not meeting national standards. Paediatric consultant presence on the children’s unit was not in line with national standards and not all patients were seen by a consultant within 14 hours of admission.
  • Records in maternity were not always complete. Updated risk assessments for each woman had not been completed. A records audit had not been completed in the 12 months prior to our inspection. Paper records on the neonatal unit were not stored securely. There was no formal system in place to ensure security of prescription pads in outpatients. Not all staff in maternity participated in the World Health Organisation safer surgery checklist.

Are services effective?

Our rating of effective stayed the same. We rated it as requires improvement because:

  • Maternity services and medicine were rated as requires improvement for effective.
  • Performance in national audits did not always demonstrate good outcomes for patients. The results of the 2018/19 chronic obstructive pulmonary disease audit showed that five out of the six metrics were worse than the national average and did not meet the national standard.
  • Performance in the lung cancer audit for 2018 did not meet the national standard in three out of the five metrics but were better than the national and regional average. However, compared to the 2016 audit results, performance had decreased in four out of the five metrics.
  • Stroke nurse responders were covering for vacancies and sickness on the stroke ward and were not able to leave the ward respond to a patient arriving at the hospital with an acute stroke. This contributed to a downgraded rating from B to C in the April to June 2019 national audit programme.
  • There were higher than expected risk of readmissions in medicine. From February 2018 to January 2019, patients at Bradford Royal Infirmary had a higher than expected risk of readmission for elective admissions and for non-elective admissions when compared to the England average.
  • The endoscopy unit had failed to achieve the Joint Advisory Group (JAG) for endoscopy accreditation in March 2018. There were concerns with patient flow and staff competencies.
  • In maternity services there had not been enough oversight of or concerted efforts to improve the stillbirth rate in the 12 months prior to our inspection; the annual total stillbirth rate was more than double the regional average. This had been a concern at our previous inspection.
  • In maternity we were not assured that managers always checked to make sure staff followed guidance, as some key audits had not been appropriately monitored or completed. The April 2019 to March 2020 maternity audit plan showed several audits were behind schedule, or their status was not determined.
  • The maternity service did not always provide care and treatment based on national guidance and evidence-based practice; we saw some guidance was not fully implemented or was contradictory.
  • Maternity staff did not always use the findings to make improvements and achieve good outcomes. For example, we found only one of 12 local actions from a key national audit had been implemented.
  • There was no designated smoking cessation lead midwife in post, due to withdrawal of external funding; and an opt out referral to local authority smoking cessation services had a low success rate.

However:

  • Services overall provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance.
  • The policies and guidelines we checked were within their review date. This was an improvement from the last inspection.
  • In children and young people’s services, staff monitored the effectiveness of care and treatment. They used the findings to make improvements and generally achieved good outcomes for children and young people.
  • Staff assessed patients to see if they were in pain and gave pain relief in a timely way. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.
  • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. Services made adjustments for religious, cultural and other needs.
  • Services made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and development. Staff were experienced, qualified and had the right skills and knowledge to meet the needs of patients.
  • Doctors, nurses, therapists and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care.
  • Staff gave patients practical support and advice to lead healthier lives.
  • Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. They knew how to support people who lacked capacity to make their own decisions or were experiencing mental ill health. They used measures that limit patients' liberty appropriately. Compliance rates for Mental Capacity Act (MCA) and deprivation of liberty safeguards (DoLS) training were above the trust target.

Are services caring?

Our rating of caring stayed the same. We rated it as good because:

  • We rated caring good in medicine, maternity, children and young people’s services and outpatients.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. There was a family centred approach in children and young people services.
  • Staff provided emotional support to patients, families and carers to minimise their distress. They understood patient's personal, cultural and religious needs. Staff took time to interact with patients and those close to them in a respectful and considerate way.
  • Staff supported patients’ families and carers to understand the patient’s condition so that informed decisions about care and treatment could be made.
  • All staff members displayed understanding and a non-judgemental attitude towards (or when talking about) patients who had a mental health problem or a learning disability.

Are services responsive?

Our rating of responsive improved. We rated it as good because:

  • We rated responsive good in medicine, children and young people’s services and outpatients. Responsive was rated requires improvement in maternity.
  • Services planned and provided care in a way that met the needs of local people and the communities. Services also worked with others in the wider system and local organisations to plan and coordinate care with other services and providers.
  • People could mostly access services when they needed them and received the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with national standards
  • Services were inclusive and took account of patients, families and carers needs individual needs and preferences. Staff made reasonable adjustments to help patients access services.
  • It was easy for people to give feedback and raise concerns about care received. Staff treated concerns and complaints seriously, investigated them and shared lessons learned. The service included patients in the investigation of their complaint.
  • Since our last inspection of the service, maternity had implemented an eight-bed induction of labour suite and had extended maternity assessment centre opening hours to offer 24-hour provision.

However:

  • Women could not always access maternity service when they needed it and receive the right care promptly. There had been 23 maternity unit closures over a one-year period; varying from approximately four hours to two days in duration. The birth centre had closed a further nine times. We saw women were routinely diverted to deliver at other trusts due to unit acuity and staffing.
  • There had been numerous delays to the induction of labour service. In October 2019, we saw four women had given birth in areas of the service not intended for deliveries; such as the maternity assessment centre and induction of labour suite.
  • The proportion of initial antenatal bookings undertaken before 13 weeks was below trust target.
  • There were long waiting times for children waiting for autism assessments and waiting times from referral to treatment were not always in line with national standards. However, plans were in place to address these.
  • Outpatient services were not always available seven days a week or during the evening.

Are services well-led?

Our rating of well-led stayed the same. We rated it as good because;

  • Overall, leaders were visible and approachable for patients and staff. Leaders had the skills and abilities to run services. They understood and managed the priorities and issues in their areas. They supported staff to develop their skills and take on more senior roles. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care.
  • Services had a vision for what they wanted to achieve and were developing strategies to turn it into action. These visions and strategies were focused on sustainability of services and aligned to local plans within the wider health economy.
  • There was an open culture where patients, their families and staff could raise concerns without fear. Services promoted equality and diversity in daily work.
  • Leaders operated effective governance processes. We saw senior leaders had recently implemented new roles to strengthen governance structures within the divisions. Staff were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of their service.
  • Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact. They had plans to cope with unexpected events.
  • We saw that services collected reliable data and analysed it. Staff could find the data they needed, in accessible formats to understand performance, make decisions and improvements. The information systems were integrated and secure. Data or notifications were consistently submitted to external organisations as required.
  • Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients.
  • We found staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation and participation in research.

However:

  • In maternity, we were not assured all levels of governance and management always functioned effectively and interacted with each other appropriately. Leaders did not always manage, prioritise or robustly monitor key issues the service faced. For example, with respect to identifying and acting on the stillbirth rate or monitoring incident reports of obstetric theatre use. Levels of one-to-one care in labour had not improved on average over the course of at least the last two to three years.
  • Maternity services did not always collect reliable data and analyse it. We were not assured data was always available to understand performance, make decisions and improvements; key maternity service audits had not been completed or appropriately monitored.
  • Maternity leaders and teams did not always robustly monitor and escalate relevant risks and issues and identify and implement actions to reduce their impact. There was limited evidence of leaders using the results of internal and national audits to improve key outcomes.
  • Maternity services did not have a vision agreed for what it wanted to achieve. A strategic vision was being developed though and a women’s services action plan was in place; however, some key business risks such as replacement of the obstetric theatres were omitted.
Inspection areas

Safe

Good

Updated 9 April 2020

Effective

Requires improvement

Updated 9 April 2020

Caring

Good

Updated 9 April 2020

Responsive

Good

Updated 9 April 2020

Well-led

Requires improvement

Updated 9 April 2020

Checks on specific services

Medical care (including older people’s care)

Good

Updated 9 April 2020

Our rating of this service improved. We rated it as good because:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it. Safeguarding training levels had improved since the previous inspection.
  • The service provided mandatory training in key skills to all staff and made sure everyone completed it. Compliance with mandatory training had improved since our previous inspection.
  • The service provided care and treatment based on national guidance and evidence-based practice. At the previous inspection we found that several policies and guidance had gone past their review date. At this inspection we checked six clinical guidelines and polices, and found they were all within their review date.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Staff took time to interact with patients and those close to them in a respectful and considerate way.
  • The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. The vision and strategy were focused on sustainability of services and aligned to local plans within the wider health economy. Leaders and staff understood and knew how to apply them and monitor progress.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear.
  • People could access the service when they needed it and received the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with national standards.
  • Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients' consent. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health. They used measures that limit patients' liberty appropriately.
  • Staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration. The trust had appointed a sepsis nurse in October 2018 who had rolled out a series of improvements. This included staff training, developing standard protocols and the establishment of a deteriorating patient group.

However:

  • The service did not always have enough nursing staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Despite this we found the service monitored this well and had mitigation in place to manage staffing issues.
  • Performance in national audits did not always demonstrate good outcomes for patients. The service had a higher than expected risk of readmission. From February 2018 to January 2019, patients at Bradford Royal Infirmary had a higher than expected risk of readmission for elective admissions and for non-elective admissions when compared to the England average.
  • The service had a higher than expected risk of readmission. From February 2018 to January 2019, patients at Bradford Royal Infirmary had a higher than expected risk of readmission for elective admissions and for non-elective admissions when compared to the England average.
  • The endoscopy unit had failed to achieve the Joint Advisory Group on Endoscopy (JAG) accreditation in March 2018. Staff explained this was due to concerns with patient flow and staff competencies. The service had appointed a new manager to implement an action plan to regain accreditation and staff told us that the unit was online to achieve this.

Services for children & young people

Good

Updated 9 April 2020

Our rating of this service improved. We rated it as good because:

  • We rated safe, effective, caring, responsive and well led as good.
  • Nurse staffing levels had improved and an acuity and dependency tool was in use. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank and agency staff a full induction.
  • Compliance with safeguarding level 3 training had improved and targets were being met. Staff understood how to protect children, young people and their families from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.
  • The environment on the children’s wards had improved and now met individual’s needs. The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use them. Staff managed clinical waste well.
  • The service provided care and treatment based on national guidance and evidence-based practice. Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and generally achieved good outcomes for children and young people.
  • Staff treated children, young people and their families with kindness and compassion, they provided emotional support and involved children, young people and families in decisions about their care.
  • The service was inclusive and took account of children, young people and their families' individual needs and preferences. Staff made reasonable adjustments to help children, young people and their families access services. They coordinated care with other services and providers.
  • The service had improved the time taken to deal with complaints.
  • Leaders had the skills and abilities to run the service. Staff felt respected supported and valued. All staff were committed to continually improving the services.

Critical care

Good

Updated 24 June 2016

We rated this service as good overall.

We found the relationships within the unit had improved. Senior managers now attended team meetings and were more visible on the wards. Governance structures were still not embedded and clinical leads had only recently come into post.

Staffing was adequate to meet patient needs and medical staff now worked one week in seven on ICU, in-line with national standards. Nursing staff had access to critical care training at the local university. Following the previous inspection we found that the service had reviewed the ward area and redesigned access to the sinks to improve infection control. The service planned to move the four HDU beds from a bay on a ward to a larger area which would allow patients to be cared for in a more suitable environment.

The capacity of the service to meet demand remained an issue. The bed occupancy for the unit was about 92% and patients were sometimes being cared for in recovery in the nucleus theatre because there was not a bed available on ICU. It was unclear if the new unit would be sufficient to reduce the occupancy rates because the number of ICU beds was not being increased. There had been no review of unmet demand for beds, which was identified as an action from the previous inspection and quality key indicators reports. The service was still not seeing all patients within 12 hours of admission although improvements had been made and processes put in place to mitigate the risk.

Patient outcomes information was not always completed and audits from patient outcomes were not always available. However the service did complete Intensive Care National Audit and Research Centre (ICNARC) data and it was used to benchmark against similar organisations. The service had not reviewed policies and procedures to ensure they adhered to professional standards and guidelines.

Delayed discharges of over four hours still occurred. However, the number of delayed discharges of over four hours had reduced since the last inspection and delayed discharges were better than similar units. Quicker discharges were facilitated by staff attending bed meetings to discuss discharges from ICU.

End of life care

Good

Updated 24 June 2016

We rated this service as good because people at the end of their life were cared for within the hospital by ward staff, who were supported by a hospital specialist palliative care team. This team worked closely to the national Gold Standards Framework to ensure that patients experienced a good quality of care at the end of their life. The team was supported by a consultant in palliative care medicine ensuring that appropriate and timely advice was available to staff across the wards and district. In addition, patients and their relatives had access to support through the ‘Gold Line’ a telephone service, available 24 hours a day, seven days a week.

Care was arranged to meet the needs of the individual and to ensure where possible that people were able to spend the end of their life in their preferred place of death. There were systems and arrangements in place to ensure that people’s diverse needs were respected and supported. There was collaborative working across multi-disciplinary teams and other agencies to ensure that patients with cultural, religious and special needs such as a learning disability were incorporated into their individual care packages.

Surgery

Good

Updated 15 June 2018

Our overall rating of this service stayed the same. We rated it as good because:

  • Patients were protected from abuse because staff had received training in safeguarding, there was a lead nurse for safeguarding and staff reported good support from the psychiatric liaison team.

  • Staffing numbers were reviewed regularly to ensure they were safe despite significant challenges.
  • Learning was evident in discussions with staff about incidents and staff knew how to report incidents.
  • The trust had ensured relevant staff working in surgery complied with the five steps to safer surgery process and that the WHO surgical safety checklist was consistently followed and audited.
  • Policies and pathways were based on guidance from the Royal College of Surgeons and the National Institute for Health and Care Excellence (NICE).
  • Enhanced recovery pathways were in place, for example for patients undergoing elective joint replacement surgery.
  • Staff worked together as a team for the benefit of patients. Doctors, nurses and other healthcare professionals supported each other to provide care.
  • The trust had a multi-faith chaplaincy service and bereavement service and patients confirmed staff provided emotional support. The bereavement service scored positively in recent audits.
  • All wards were dementia friendly and had a wide range of resources available for people living with and caring for people with a dementia. Specialist dementia nurses were employed by the trust and access to learning disability liaison support was available.
  • The trust’s performance for elective and non-elective admissions relating to overall length of stay was better than the England average.
  • The surgical division had a management structure in place with clear lines of responsibility and accountability; senior staff were motivated and enthusiastic about their roles and had clear direction with plans in relation to improving patient care.
  • Staff told us the division had strong leadership and senior managers were visible and engaged with staff.

However:

  • Although staff received mandatory training, compliance rates were variable; the rates of completion for Mental Capacity Act training and also for the completion of staff appraisals were below trust targets.
  • Environmental issues were identified with floors in theatres although these were in the process of being addressed by the trust.
  • The trust recognised there remained a risk of contamination of the clean scrub area during the movement of dirty instruments from theatre.
  • The trust had higher than expected risks of readmission for both elective and non-elective admissions when compared to the England averages.
  • The percentage of cancelled operations at the trust was higher than the England average.
  • The trust had received a concern from the National Joint Registry Outlier Committee drawing attention to the mortality rate for knee replacements.
  • The trust was not meeting its policy that complaints should be resolved within 30 days of receipt and took an average of 55 days to investigate and close.
  • Patients described the care they received in positive terms and friends and family recommendation rates were over 90% but response rates were very low.

Urgent and emergency services

Good

Updated 15 June 2018

A summary of our findings about this service appears in the overall summary.

Our overall rating of this service improved. We rated it as good because:

  • Patients were clinically streamed on arrival in the department, with the oversight of qualified nurses and triaged promptly, usually with medical input.
  • Staff acted promptly to escalate their concerns when a patient’s condition deteriorated, so that the patient received the most appropriate care and treatment.
  • Patients consistently gave positive feedback about their experience in the emergency department. Staff provided appropriate and timely support to help patients cope emotionally with their care and treatment.
  • Almost all patients were assessed with 15 minutes of arrival during our inspection, which mainly met our previous concerns that not all patients were being assessed promptly, and waiting times of patients between four and 12 hours showed a long term trend of improvement.
  • An agreement with a neighbouring mental health trust provided support for patients experiencing ill mental health and we observed this multidisciplinary arrangement worked well although we did observe some delays for assessment.
  • Medical and nursing staff, of all grades, were deployed in sufficient numbers to support a safe service, staff received regular appraisals and staff development opportunities were consistently well received by staff.
  • The emergency department followed recognised evidence-based care and treatment guidelines and participated in national audits to enable its practice to be compared.
  • The emergency department had implemented electronic patient records so that the records of patients were complete, accessible, audited and met our previous concerns as to patient confidentiality.
  • Staff reported incidents and applied safeguarding procedures for adults and children appropriately; Staff had an appropriate understanding of consent, mental capacity, and deprivation of liberty safeguards.
  • Risks were identified, regularly reviewed and mitigation and action was taken. the department’s processes and systems were reviewed through regular audit and monitored to support improvement.
  • The new emergency department met our previous concerns about the limitations of the previous department’s facilities; the department worked closely in liaison with the acute assessment area, the medical admissions unit and the ambulatory care unit to support the efficient flow of patients.
  • Leadership and governance of the emergency department was stable with elements of good practice and staff spoke positively about the clinical leadership of the department; medical and nursing staff at all levels were clear about their roles; the culture was positive, friendly and open with high staff morale.
  • The vision and strategy for the emergency department was supported by the clinical services strategy for 2017 to 2022 and the department embraced the overall mission of the trust to provide the highest quality healthcare.
  • Information was used to monitor and manage the operational performance of the department, and to measure improvement.

However:

  • The layout of the reception area did not support the confidentiality of patients.
  • Signposting to the emergency department in the hospital needed to be improved.
  • Nurse practitioner recruitment needed to be completed so that the ambulatory care unit (ACU) was fully staffed for extended hours.
  • Mandatory training needed to be fully completed by all staff, including staff training and competency assessments to support the safe use of patient group directions.
  • Improvements were required for sepsis outcomes for the emergency department, the unplanned re-attendance rate within seven days and to the high number of patients leaving the department before being seen.
  • Some key operational performance information (particularly compliance with the 95% standard) was not presented clearly in the emergency department.
  • Information for patients was not available in the reception area and further information in printed form was not available for patients and their carers, particularly about the support available for patients with mental ill health, dementia or learning disability.
  • The friends and family test for the emergency department had achieved a very low response rate particularly in the last 12 months.
  • The trust’s policy commitment to resolve complaints within 30 days was not always being met, although recent improvements in complaint handling had been achieved.
  • The links with primary care services needed to be developed further to support the emergency department’s role in health promotion and the use of joint patient pathways to avoid unnecessary referrals to the emergency department.

Maternity

Requires improvement

Updated 9 April 2020

Our rating of this service stayed the same. We rated it as requires improvement because:

  • The delivery of high-quality care was not assured by the leadership or governance of the service. Senior leaders had failed to monitor or improve performance in several fundamental areas of maternity service care. For example, there were ongoing midwifery staffing challenges in the service, and we observed poor levels of one-to-one midwifery care in established labour, and hourly ‘fresh eyes’ reviews of CTGs.
  • The design of the environment and ventilation equipment in theatres did not adhere to national guidance. Incident reporting of obstetric theatre two use had been inconsistent and had not been robustly monitored by senior managers in the service; despite this being a key control to mitigate against infection risk.
  • Senior leaders did not always robustly identify, manage, prioritise or monitor key issues the service faced. For example, they had not sufficiently identified and acted on increases in the stillbirth rate during 2019. The annual total stillbirth rate (adjusted to exclude lethal abnormalities) was more than double the regional average.
  • Review of intrapartum (and to a lesser extent, postpartum) records showed staff did not always complete and update risk assessments for each woman and act to remove or minimise risks. A records audit had not been completed in the 12 months prior to our inspection. Not all staff were engaged with and participated in the WHO safer surgery checklist.
  • We saw some national and evidence-based practice guidance was not fully implemented or was contradictory. We were also not assured that managers always checked to make sure staff followed guidance, as some key audits had not been appropriately monitored or completed. The April 2019 to March 2020 maternity audit plan showed several audits were behind schedule, or their status was not determined. We saw limited evidence of leaders using the results of internal and national audits to improve key patient outcomes.
  • Women could not always access the service when they needed it and receive the right care promptly. There had been 23 maternity unit closures over a one-year period. Women were frequently being diverted (at an average rate of one per week) to other NHS trusts because of staffing and acuity challenges.

However:

  • Following our recent inspection, we noted several areas identified for improvement at our last (2018) inspection of the service had been addressed. For example, we saw unit security had been improved, staff received annual appraisals, maternity policies and guidelines were up to date, and overall compliance with mandatory training exceeded trust targets. We also saw fridge temperature monitoring was embedded, checklists for resuscitaires had been revised, there were quality control checks for fetal blood gas analysers, and patient information leaflets were up to date.
  • Staff treated women with compassion and kindness, respected their privacy and dignity, took account of their individual needs; and provided emotional support to women, families and carers to minimise their distress. We also identified elements of outstanding care, with respect to the ‘butterfly pathway’ and palliative care provision.

Outpatients

Good

Updated 9 April 2020

Our rating of this service improved. We rated it as good because:

  • The service provided mandatory training in key skills to all staff and made sure most completed it.
  • Staff understood how to protect patients from abuse.
  • The service had enough competent staff and they worked together as a team.
  • Records were clear, up-to-date and stored securely.
  • The service used systems and processes to safely prescribe, administer, record and store medicines.
  • The service managed patient safety incidents well and monitored the effectiveness of care and treatment.
  • Staff treated patients with compassion and kindness.
  • Leaders had the skills and abilities to run the service.
  • Staff felt respected, supported and valued.

However, we also found:

  • The service did not always control infection risk well, although they kept the premises visibly clean.
  • Outpatient services were not always available seven days a week.
  • There were gaps in emergency equipment check records.
  • There was no formal system in place to ensure security of prescription pads.