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Inspection Summary


Overall summary & rating

Inadequate

Updated 9 June 2021

The Jessop Wing opened in 2001 and is a purpose-built maternity unit with approximately 6,200 babies born at the trust every year.

In addition to a 22-bed labour ward, there are two postnatal wards, one antenatal ward, an admission triage area and an

advanced obstetric care unit One of the postnatal wards specialises in caring for women who have had a caesarean section. In addition, the Jessop Wing community midwifery service supports approximately 200 homebirths per year.

The Jessop Wing also provides neonatal intensive care and special care for sick and premature babies born in Sheffield and those transferred from other units who require this service.

The antenatal clinic and gynaecology outpatient clinic are on the ground floor of the Jessop Wing. The gynaecology service also includes two wards on G Floor of the Royal Hallamshire Hospital. At the time of the inspection one ward of G Floor was closed due to COVID-19. The Jessop Wing has an assisted conception unit for women who require this specialist treatment. We did not inspect this service.

We carried out this unannounced focused inspection because we received information that highlighted concerns about the safety and quality of the services.

During the inspection we inspected the labour ward, two postnatal wards, antenatal ward, admission triage area, advanced obstetric care unit. We spoke with 22 staff, including senior leaders, service leads, matrons, midwives, medical staff, maternity care support workers and student midwives. We reviewed 11 sets of records and observed staff providing care and treatment to women.

Focused inspections can result in an updated rating for any key questions that were inspected. This can be if we inspect the key question in full across the service and/or where we had identified a breach of a regulation, and issued a requirement notice or taken action under our enforcement powers. In these cases, the ratings will be limited to requires improvement or inadequate.

Following this inspection, under Section 31 of the Health and Social Care Act 2008, we imposed urgent conditions on the registration of the provider in respect to the regulated activity; Maternity and midwifery services. 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. Imposing conditions means the provider must manage regulated activity in a way which complies with the conditions we set. The conditions related to the maternity units at Sheffield Teaching Hospital NHS Foundation Trust’s Jessop Wing.

We rated maternity services as inadequate. Overall, we rated safe, and well-led as inadequate. The ratings for effective went down to requires improvement and responsive was not rated and stayed the same.

Our rating of services went down. We rated them as inadequate because:

  • We were not assured the trust always had effective systems in place to ensure that medical and midwifery staff had the skills, competence, knowledge and experience to safely care for and meet the needs of women and babies within all areas of the maternity service.
  • Staff did not always complete and update risk assessments for each patient and did not always take timely action to minimise and mitigate risks.
  • The service did not always manage patient safety incidents well. There were delays in the investigation of incidents and lessons learned were not always shared amongst the whole team and the wider service. When things went wrong, there were concerns that there was a lack of openness and transparency.
  • We were not assured the leaders had the skills, knowledge and experience to run the service. We were concerned that leaders within the service were not effective at implementing changes that improved the quality and safety of care delivered.
  • Leaders did not operate effective governance processes to continually improve the quality of the service and safeguard the standards of care.
  • There was mixed performance on patient outcomes, but they didn’t always use findings to make improvements and achieve good outcomes for women.
  • We were not assured that the service collected reliable data and analysed it effectively. Data was not always in easily accessible formats due to the multiple systems in use. Data or notifications were consistently submitted to external organisations as required, but recommendations were not always shared or implemented in a timely manner.

However:

  • Staff understood how to protect women 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.
  • Doctors, midwives and other healthcare professionals worked together as a team to benefit women.
Inspection areas

Safe

Inadequate

Updated 9 June 2021

Effective

Requires improvement

Updated 9 June 2021

Caring

Updated 9 June 2021

Responsive

Updated 9 June 2021

Well-led

Inadequate

Updated 9 June 2021

Checks on specific services

Maternity

Inadequate

Updated 9 June 2021