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Inspection carried out on 9 – 11 December 2014 and unannounced visits: 13 and 14 January 2015

During a routine inspection

The Princess Anne Hospital is part of University Hospital Southampton NHS Foundation Trust, which has had foundation status since 1 October 2011. The hospital provides maternity and gynaecological services, and is across the road from the main general acute hospital. Services are provided to the local community of Southampton City, and areas of Hampshire and the New Forest.

Neonatal services are also provided at this location but were inspected under services for children and young people , in the Southampton General Hospital location report.

The trust had 80 maternity beds. Midwife-led and obstetrician-led services are provided for early pregnancy, antenatal, induction of labour and postnatal care. There is an antenatal clinic and early pregnancy assessment unit, a four bedded day assessment unit and a four bedded induction of labour ward. Inpatient care is provided on Lyndhurst Ward (12 beds primarily used as antenatal beds, but often also housing postnatal women and babies) and Burley Ward (a 22 bedded postnatal ward). The Broadlands Birth Centre, a midwife-led unit near the main obstetrics unit, consists of four birthing rooms, two of which are equipped with pools and four postnatal beds for newly delivered mothers and babies. The delivery suite consists of 15 birthing rooms. One of these rooms is used as a bereavement room, one contains a pool, and there is a two bedded high dependency bay. The theatre suite adjacent to the delivery suite comprises of two obstetric operating theatres.

There is also a free standing midwife-led unit known as the New Forest Birth Centre, located in Ashurst on the edge of the New Forest. The unit has seven postnatal beds, three of which are single rooms, and two birthing rooms with pools. Findings from our inspection of this unit are included in this report on maternity services.

The gynaecology service is provided in a 21 bedded gynaecology and breast care ward (Bramshaw), a gynaecology outpatients area, and a two chaired hyperemesis unit.

The inspection was part of an announced trust-wide inspection which took place on 10 and 11 December 2014, with unannounced visits on 13 and 14 January 2015. The team inspecting this location included CQC inspectors and analysts, doctors (obstetrician and gynaecologists), head of midwifery and gynaecology, and midwives.

Overall we rated the Princess Anne Hospital as ‘Good. We rated it good’ for providing effective, caring, responsive and well-led maternity and gynaecological services. But it ‘required improvement’ under safe services.

Our key findings were as follows:

Is the service safe?

  • Incidents were reported and lessons were learnt and shared to prevent the likelihood of reoccurrence.

  • All areas were visibly clean, and staff were seen to adhere to good infection control and hand hygiene practices.

  • Staff were supported to identify and support women and babies at risk. Risk assessments were undertaken and actions to reduce the likelihood of harm occurred.

  • Hoisting equipment was available on Bramshaw Ward. But not all staff were aware of the location or correct use of equipment for the safe evacuation of a woman that may have collapsed in a birthing pool on the delivery suite or at the Broadlands Birth Centre.

  • There were two fully staffed obstetric theatres from 8am – 1pm every weekday. At all other times one theatre was immediately available for emergencies and a second team available to be called upon if the second theatre was needed.

  • One of the four operating tables could not be lowered adequately, and surgeons were required to stand on stools which increased the risk of back injuries to the surgeon and patient risks during surgery.

  • The building was originally designed and built to provide a maternity service to 4,000 women and far fewer deliveries than the 5,812 births which took place between 1 April 2013 and 31 March 2014. As such, some areas were overcrowded, including the day assessment unit and the induction suite.

  • Staff and patients told us some rooms in maternity services were cold ; we found windows were poorly fitted and single glazed which made them draughty.

  • The funded midwife to birth establishment was 1:28 and was below the England average of 1:29. The RCOG also states that there should be an average midwife to birth ratio of 1:28. However, with sickness and maternity leave, the current ratio was 1:31. Midwives were being allocated to women to provide one to one care, but frequently worked in different areas in order to do so. As a result, midwifery staffing on the ante and postnatal areas was, at times, below the recommended numbers, and this had resulted in the care of women in these areas being delayed.

  • The trust reported 98 hours dedicated consultant cover on the delivery suite, which fell below the recommended 168 hour consultant presence to meet the recommendations of Royal College of Obstetricians and Gynaecologists, Safer Childbirth (2007). There was a separate on-call rota for gynaecology and obstetrics, which meant medical staff were not required to provide cover to both areas. Consultants were present during weekends, undertaking ward rounds and providing on-call support to nursing staff, midwives and junior doctors.

Is the service effective?

  • The care and treatment delivered to women was evidence-based. Policies and guidelines were developed in line with national guidance.

  • Staff encouraged normal birth in the maternity service. The caesarean section rate was below the England average and the normal delivery rate was comparable to the England average This results in a higher than average number of assisted deliveries.

  • A wide range of pain relief was available. Post-operative pain was managed with patient-controlled analgesia, polices existed to support the management of pain in the latent phase of labour, and women in labour had access to epidural anaesthesia at all times on the delivery suite.

  • Staff received training and support to maintain their competence. The supervisor of midwives (SoM) ratio was 1:15, equal to the nationally recommended ratio. There was good, supportive multidisciplinary team working. Multidisciplinary clinics were held for women with complex care needs.

  • The processes for women to consent were appropriate. Staff had appropriate knowledge of the Mental Capacity Act 2005, and there was support available in the event of a concern regarding a woman’s capacity to make decisions.

Is the service caring?

  • Care was seen to be delivered with kindness and compassion. Women were involved in decision-making, and staff ensured understanding and involvement of patients and their partners/relatives, and emotional support through good communication.
  • Patients told us their experience of care was good. The NHS Friends and Family Test (FFT) response rates were in line or higher than the national average. The service performance dashboard indicated 98% of gynaecological patients were satisfied with the care they had received. Results for the maternity service for December showed 73.8% of women were extremely likely to recommend the service.

Is the service responsive?

  • Women were able to make choices on where to have their babies, with the choice of home, midwife-led care in a free standing birth centre, midwife-led care in an alongside birth centre or obstetric-led care. Women were also able to receive ante and postnatal care and support in the New Forest Birth Centre.

  • There were two fully staffed obstetric theatres every weekday morning. At all other times one theatre was immediately available for emergencies. Access was delayed for non-emergency procedures, such as the repair of third and fourth degree perineal tears, but the number of delays had reduced with the opening of the second theatre in the morning.

  • The provision of gynaecological care occurred within the 18 week referral to treatment (RTT) national target timeframe. Theatre slots were filled based on the needs of women, and regular theatre slots were allocated to the early pregnancy assessment centre to facilitate surgery within 24-48 hours if required.

  • Women had access to information to support their diagnosis or pregnancy options. Some information was available in different languages.

  • Translation services were available. Staff were able to access support for patients with additional needs, such as learning disabilities and mental health needs.

Is the service well-led?

  • The maternity service was in the process of developing a new vision and strategy which would involve changes to the way midwives worked to deliver care. This had involved staff surveys and a listening event, with a plan to fully involve staff and service users in the onward development. A strategy for the gynaecology service was not developed.

  • The service had a well-defined governance structure. Specialist midwives and administration staff were employed to support the governance function.

  • Staff were positive about the support from the senior staff and immediate managers, and there were plans to support succession planning. Staff described an open culture which encouraged honesty, and were able to describe changes in practice as a result of this. Success was praised. Not all staff, however, felt connected with the main trust.

  • Services were implementing a number of new innovations. The maternity service had worked with local universities to develop changes to the midwifery course to establish two cohort intakes per year from February 2016, in order to provide a steadier stream of new midwifery staffing to the service.

We saw several areas of outstanding practice, including:

  • Midwives who held a caseload (named as caseload midwives) worked in areas of greatest deprivation and with the largest number of teenage pregnancies. These midwives had smaller caseloads and provided greater continuity of care, and often followed the women into the maternity unit to deliver.

  • There was a ‘birth afterthoughts’ service which enabled women to have a debrief with a midwife following their delivery. Themes from this service were identified and fed into the governance process. Over 400 women had accessed the service during 2014.

  • Women with hyperemesis could be cared for as day case patients and receive intravenous fluid rehydration. This meant they could remain at home and this helped to prevent admission.

  • A telephone triage service with a neighbouring trust had been agreed and was about to be implemented. This initiative would direct women to the appropriate place for care.

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

Importantly, the trust must ensure:

  • Operating tables can be lowered adequately, so surgeons are not required to stand on stools, increasing the risk of back injuries to the surgeon and patient risks during surgery

  • Ensure all staff are aware of the location or correct use of equipment for the safe evacuation of women from the birthing pools.

The trust should:

  • Review acuity and midwifery staffing levels to ensure adequate care in all sectors of the service at all times.

  • Review consultant cover on the delivery suite in line with RCOG, Safer Childbirth (2007).

  • Review systems to ensure that all babies receive newborn examination checks in the appropriate time frame.

  • Ensure that action is taken to improve temperature control in rooms in maternity services which were cold at times, with poorly fitted and single glazed windows which make them draughty.

  • Ensure staff are aware of the how the new call bell system works, and that there are sufficient call bell panels for staff to ascertain location of emergencies.

  • Review the times of provision of a dedicated second obstetric theatre, extending availability to further reduce delay in non-urgent procedures.

  • Continue to review the facilities for the induction of labour, to ensure there is sufficient space and capacity to provide adequate privacy and dignity, and to meet demand and reduce waiting times for women.

  • Review the provision of facilities for women and their partners to make drinks or have snacks on wards without the need to leave the wards to access vending machines.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 10 December 2012

During a routine inspection

During this inspection we inspected the inpatient maternity and midwifery services. We visited the in patient wards providing antenatal and postnatal care and the labour ward including induction and day unit. We spoke with three mothers and their partners about their experiences and care they had received. All were very positive and felt they had been consulted and involved in treatment decisions. They were happy with the care they had received and felt that staff had been available when they were required. Staff working on the wards and labour ward said they usually had enough time to meet people’s needs. Records of care provided on the postnatal ward and discussion with labour ward midwives and medical staff showed that people were receiving appropriate care.

The inspection lasted one day and one inspector was accompanied by a clinical advisor with specialist knowledge and experience in maternity services.