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Addenbrooke's and the Rosie Hospitals Good

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Inspection report

Date of Inspection: 6 September 2011
Date of Publication: 28 December 2011
Inspection Report published 28 December 2011 PDF | 54.03 KB

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Meeting this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

We reviewed all the information we hold about this provider and carried out a visit on 06/09/2011.

Our judgement

Feedback and quality monitoring information is reviewed by the trust to ensure the safety and welfare of women is maintained. However to maintain compliance the trust must continue to monitor incidents and the quality monitoring records of one to one care for women in established labour so that identified risks are appropriately managed.

User experience

The trust supplied us with information they had used from inpatient surveys to improve the maternity service. At the beginning of 2011, the information shows that the overall satisfaction levels fell below acceptable levels in one area of the maternity unit. The trust took action and women are now more satisfied with the service indicating that the planned improvements have been effective.

Other evidence

We spoke with staff on the maternity unit about the NHS staff survey results for the trust in 2010, where the overall result had reported a rise in near misses, and incidents. They told us that they report errors through an electronic reporting system, but were not aware that incident reports had increased. Several staff could describe the process for investigating moderate and serious issues and gave examples where practice had been changed to minimise risk. In respect of this the management of the maternity unit provided us with the last three quarterly monitoring reports; the most recent report for maternity services, covering April to June 2011, indicated that there has been an increase in reported incidents in this service in the last 12 months, however the number of serious issues reported has remained stable. The trust had investigated all serious issues and had acted upon their findings and taken relevant action as needed to improve practice.

Quality monitoring information supplied by the trust showed that the records of one to one care for women in established labour were poor, which we were advised was partly due to changes in the recording system. The trust advised that they planned to review three full months of data in November 2011.

Staff told us that they are kept informed of best practice and policy changes through regular emails, monthly team meetings and weekly ward meetings. We saw evidence that this is in place.