Liverpool Women's Hospital

Updated 28 February 2024

We inspected gynaecology services at Liverpool Women's Hospital as part of the comprehensive inspection of Liverpool Women's NHS Foundation Trust. We also carried out a short notice announced focused inspection of the maternity service, looking only at the safe and well-led key questions, as part of our national maternity services inspection programme.

Gynaecology

The Liverpool Women's NHS Foundation Trust gynaecology division, is a tertiary referral centre for gynaecology, performing approximately 10,000 procedures per year. The division primarily runs the services from the main hospital site at Crown Street, but also has sites at Aintree. The division has a number of services within it, fertility medicine, inpatient gynaecology and day case, colposcopy and hysteroscopy, ambulatory care, a gynaecology emergency department, a termination of pregnancy unit, a two bedded high dependency unit and gynaecology oncology.

The Bedford Unit provides termination of pregnancy services including early medical abortion (up to 16 weeks plus 6 days gestation) and surgical abortion (up to 12 weeks plus 6 days gestation).

We carried out an unannounced comprehensive inspection of gynaecology and termination of pregnancy using a risk-based methodology and a combined core service framework. Two inspectors and a specialist advisor were on site for two days, with offsite support from an inspection manager, head of inspection and data analysts.

We had the opportunity to speak with 4 patients using the service and looked at patient feedback shared with the commission prior to inspection. We also spoke with 41 different members of staff working across the service.

We reviewed service 15 combined electronic and paper patients’ records.

See main report for overall summary and findings.

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

• The service had enough nursing staff to care for patients and keep them safe. Nursing staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They mostly managed medicines well. The service learned lessons from safety incidents. Staff collected safety information and used it to improve the service.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
• Staff treated patients with compassion and kindness, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually. The Bedford Unit had been awarded an internal Gold rating on 14 October 2022 for ‘Be Brilliant Accreditation System’(BBAS) for KPI compliance.

However

• Completion rates in some mandatory training for medical staff were low, and key learning regarding the Oliver McGowan Mandatory Training on Learning Disability and Autism was still being planned. Although electronic records showed equipment had been checked, some equipment did not display test servicing dates. Some medicines delivered by post for termination of pregnancy had been incorrectly delivered, however this related to one incident relating an external delivery company. Medical staff were not always available in a timely way to complete patient reviews in some parts of the service. The service used systems for managing patient safety incidents, although historically there had been some delays in reporting serious incidents, but this had improved.
• We requested but did not receive data for completed appraisals for medical staff.
• Women’s privacy and dignity was not always maintained when attending for day case admissions.
• Key services were not always available seven days a week. People could not always access the service when they needed it and often had to wait too long for treatment, particularly for cancer pathways and scan services.

Maternity

We inspected the maternity service at Liverpool Women’s Hospital as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out a short notice announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

The inspection was carried out using a post-inspection data submission and an on-site inspection where we observed the environment, observed care, conducted interviews with patients and staff, reviewed policies, care records, medicines charts and documentation.

Following the site visit, we conducted interviews with senior leaders and reviewed feedback from women and families about the trust. We ran a poster campaign during our inspection to encourage pregnant women and mothers who had used the service to give us feedback regarding care. We analysed the results to identify themes and trends.

Liverpool Women’s Hospital is the main site for maternity services for the trust. It comprises of a delivery suite with maternity theatres, induction of labour beds and some enhanced recovery rooms. There is a 52 bed post and antenatal ward called Mat Base, which also contains transitional care beds. The service has a maternity assessment unit (triage) and early pregnancy assessment unit (which is part of the gynaecology emergency department). The service also has fetal medicine and maternal medicine units which provide services to women and birthing people from across the Merseyside, Cheshire and Northwest region. Ante and postnatal clinics are also provided at this location and there is an alongside midwifery led birth unit.

The local maternity population come from higher levels of deprivation than the national average with 47% in the most deprived decile compared to 13% nationally. Fewer mothers were Asian or Asian British or Black or Black British compared to the national averages.

During our inspection we spoke with staff including midwives, student midwives and doctors, maternity support workers, midwifery matrons, junior doctors, middle grade obstetricians, consultant obstetricians, as well as administration and clerical staff and senior managers. We also spoke to 9 women, birthing people and families.

Following this inspection, under Section 29A of the Health and Social Care Act 2008, we issued a warning notice to the provider. We took this urgent action as we believed a person would or may be exposed to the risk of harm if we had not done so.

Our rating of this service went down. We rated it as requires improvement because:

• Not all staff had training in key skills.
• Some staff did not always adhere to infection prevention and control best practice. Cleaning records were up-to-date but they did not always demonstrate that all areas were cleaned regularly.
• Staff did not consistently assess risks to woman and birthing people nor act on them. Frequent staff shortages increased risks to women and birthing people across the maternity service.
• Women and birthing people could not always access the service when they needed it nor receive treatment within agreed timeframes and national targets.
• The service did not always have enough maternity staff to keep women safe from avoidable harm and to provide the right care and treatment. Staffing levels did not always match the planned numbers.
• Staff did not always keep good care records.
• Staff did not always use systems and processes to safely prescribe, administer, record and store medicines.
• The service did not always manage safety incidents well nor learn lessons from them.
• Staff felt did not always feel respected, supported and valued. They were not always able to focus on the needs of women and birthing people receiving care.
• Leaders did not operate effective governance systems. They did not always manage risk, issues and performance well. They did not consistently monitor the effectiveness of the service. Though staff were committed to improving services they did not always have the skills and resources to do so.
• Managers did not always ensure staff were competent. Not all staff had received an annual appraisal.

However:

• Staff worked well together for the benefit of women and birthing people and understood how to protect women and birthing people from abuse.
• Local leaders had the skills and abilities to run the service and were visible and approachable in the service for women and birthing people and staff.
• Staff understood the service’s vision and values, and how to apply them in their work. Staff were clear about their roles and accountabilities.
• The service engaged well with women and birthing people and the community to plan and manage services.

How we carried out the inspection

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Updated 23 June 2023

Updated 22 May 2015

Patients who were considered to be in the last year of life were cared for in one of two specialist end of life suites on wards within the hospital (whenever possible). The Mulberry and Orchid suites were part of gynaecology ward 1 and provided patients with a private and calm environment where they could be cared for in an appropriate and tranquil setting. Patients and those close to them valued the environment and some patients had chosen the suites as their preferred place to die. The specialist palliative care team responded to the needs of patients in a timely way and were accessible to ward staff for support, advice and mentoring. There was good multidisciplinary working for the benefit of patients. Staff participated in regional and national networks to support service development and improvement. Staff were caring and compassionate and there was evidence of individualised, person-centred care. Processes for rapid discharge were in place to allow patients to return quickly to their preferred place of care. However, we did not see robust evidence of advanced care planning and ‘do not attempt cardio-pulmonary resuscitation’ (DNACPR) decisions were not always made in a timely way so that patients could be involved in the decision making.

Updated 28 February 2024

Updated 22 April 2020

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

The service had enough staff to care for patients and keep them safe. Staff had training in key skills and understood how to protect patients from abuse. They controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed the prescribing and administration of medicines well. The hospital managed safety incidents well and learned lessons from them. The service continually monitored safety information and used it to improve the service.

Staff provided good care and treatment, used special feeding and hydration techniques where necessary, and gave them pain relief when they needed it. Managers monitored the effectiveness of the services and made sure staff were competent. Staff worked well together for the benefit of patients and their families, advised and supported them to make decisions about their care.

Staff always treated patients and their families with compassion and kindness and feedback from parents was that they went the extra mile and completely involved them in their care. They provided emotional support to minimise the distress of patients and their families recognising the importance of their wellbeing. We heard examples of how they went the extra mile to support people and provide memories for bereaved families.

The service planned care to meet the needs of local people, they took account of patients’, parents and their families individual needs, and made it easy for people to give feedback. People could access the hospital when they needed it and did not have to wait too long for treatment.

Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care and had a vision and strategy that supported this. Staff were clear about their roles and accountabilities. The hospital engaged well with patients and the community to plan and manage services and all staff were committed to continually improving services.

However;

We found an inconsistent approach to the daily checks of resuscitation equipment and emergency equipment was not stored in tamper evident trolleys. Staff could not easily identify if equipment or sundries were missing.

Key services were not always available seven days a week to support timely care for children, young people and their families.

There was not a robust governance process in place for monitoring adherence to the checks of emergency equipment and medication.

The service did not consistently use systems and processes to safely store medicines. We found out of date emergency medicines in the emergency medicines kit on the low dependency unit.

We issued the trust with a warning notice which asked them to make improvements in medicines management by 10 January 2020. This was reviewed during our inspection in January 2020 and we will continue to monitor trust progress in relation to this.

Updated 23 June 2023

Updated 22 May 2015

There was good practice in the outpatient and diagnostic imaging departments to promote the safety of patients and staff. There was a clear process for reporting and investigating incidents. Learning from incidents was shared and there were examples of changes in practice in response to incidents. Cleanliness and hygiene in the department were of a good standard. Regular hand hygiene audits showed an appropriate level of compliance. Patient records were generally available for clinics although there were occasions when they were not. It was not possible to ascertain how widespread the issue was because incidents that related to the availability of patients’ notes were not reported consistently and the availability of notes was not audited. Staff and managers could not tell us the percentage of notes that were unavailable. The issue was recorded on the risk register a week before the inspection started. Staff were aware of the policies and procedures to protect and safeguard children and adults, and training statistics showed that most staff had completed training in safeguarding for both children and adults. Other mandatory training courses were well attended and staff were positive about the training provided. They had also been trained in managing major incidents. Staffing was generally good; however, there were occasions when the foetal medicine unit was understaffed and managers were looking at ways to resolve this. The diagnostic imaging department used a private provider for sonography to address staff shortages. There was no evidence at the time of our inspection that this was having an impact on patient safety.

Updated 22 May 2015

There were robust systems for the reporting of incidents and the management of risk within the Bedford Centre. The centre was visibly clean, medicines were safely stored and well managed, and the standard of record keeping was good. There were sufficient well-trained nurses to provide safe and effective care. The multi-disciplinary team worked well together, using national guidelines to treat patients. Access to information was good and there were robust processes in place to gain consent. Services were delivered by caring and compassionate staff who treated patients with dignity and respect. Care and treatment was planned and delivered in a way that took into account the wishes of the patient. Access to treatment, advice and information was good both during procedures and after discharge. Complaints were well managed. The trust’s vision and values for the organisation had been well communicated to staff. There was a ‘no blame’ culture that gave staff confidence to report incidents and ‘near misses’. We saw individual members of medical and nursing staff who displayed good leadership skills and were positive role models for staff generally.