Great Western Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last we rated this key question requires improvement. At this inspection the rating was requires improvement.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

We scored the service as 3. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The maternity service had not developed their own vision, but they were working towards the trusts local strategic vision, with the values being service, teamwork, ambition and respect. Trust priorities were outstanding care, valued teams, better together and sustainable future.

The trust strategic plan did not identify any specific plans for maternity but instead focused on the trust vision as a whole and how this aligns to local services. The director of midwifery’s (DOM) priority since they had come into post, was for maternity to create a strategic plan with input from both maternity staff and women and their families who use the service.

The maternity strategy continued to align against the trust priorities and vision; however, it also set out the priorities, vision and future of maternity services. The service was working alongside local maternity trusts through the local integrated care system to create a 10-year plan. The strategic plan had a timeline with realistic and clear timeline for delivering the identified measures.

The plan stated that the service planned to provide outstanding maternity and neonatal care that is ‘safe, personalised and inclusive and they are committed to creating and delivering services with women, families and the local community.’ The service worked alongside the maternity and neonatal voice partnership (MNVP) to take part in a bi monthly triangulation meeting to review women and families feedback including complaints and compliments.

We scored the service as 3. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation.

Prior to the appointment of the director of midwifery (DOM), there had been a period of instability in the senior leadership team with the DOM and governance lead posts being vacant. These roles at the time of the inspection had just been filled.

The maternity service was led by the director of midwifery (DOM) a head of midwifery (HOM), band 8 matrons and a number of specialist midwives. The MNVP was part of the interview team and supported in the recruitment for both the DOM and HOM role.

We found the maternity leaders understood and were working through managing the priorities and issues the service faced and we saw there was an open and responsive culture in addressing the risks.

All staff we spoke with were complimentary of maternity senior leaders and told us they were visible, inclusive and responsive. Leaders were valued by staff who told us they were well supported by their line managers. Staff felt supported by their colleagues about concerns or personal issues.

The director of midwifery told us they were proud of the voice senior leaders had when reporting into the executive board. The executive team were reported to be approachable and understood the pressures of the maternity service.

The DOM reported a compassionate leader approach was used for improving the maternity service alongside maternity staff, obstetrics and women using the service.

Trauma and Risk Management (TRiM) trained practitioners from both medical and midwifery backgrounds, assisted with debriefing if there was an incident. Staff had access to individual support and counselling services. The TRiM practitioners were trained to provide psychologically informed responses to traumatic events.

We scored the service as 3. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Senior leaders and staff demonstrated openness, honesty, and transparency, with many staff reporting their immediate managers were approachable, listened attentively, and provided regular feedback. Most staff we spoke to felt encouraged to raise concerns and felt heard or their concerns were acted upon.

Information about the role of the freedom to speak up guardian was displayed throughout the workplace and staff felt confident to access support.

We scored the service as 3. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Leaders worked closely and dynamically with the local MNVP to contribute to decisions about care in maternity services.

Quality and safety improvement training was available for all staff, to ensure a continuous improvement culture. The training focused on identifying reducing harm, improvement measures and mitigating risks.

The service had a live dashboard for equality, diversity and inclusion. The dashboard had been produced with the informatics team to make sure all data was able to be reviewed and actioned. This meant the service could identify areas for improvement and focus on supporting women. For example, a patient safety theme noted there was difficulties accessing translation services for all languages. The service was reviewing data from the trust maternity dashboard, national maternity dashboard and incident data to identify trends and prioritise areas for development in translations services.

The service was working alongside the maternity and neonatal single delivery plan to review its approach to having an anti-racist workplace culture and the service had a listening event with staff to understand their experiences to identify barriers to inclusion, and to produce an equitable and respectful working environment.

The trusts changing and growing together mentoring and talent programme was a skills-based development programme to strengthen cultural awareness, leadership confidence and inclusive practice within the maternity workforce.

We scored the service as 1. Although the service had clear responsibilities, roles and systems of accountability, there were areas of the service where improvements required were not always managed in a timely way.

Despite the service having governance systems and processes, we saw persistent areas of concern which could pose a risk of women and babies. Staff did not always act on information about risk, performance and outcomes to ensure high quality care for women

The service had a large number of overdue incidents waiting for review and closure. The service reported at the time of the inspection there were 77 incidents open, none of the open incidents were severe harm. Incidents which were moderate harm had an ongoing safety review and the remaining incidents were either low or no harm.

There was a focus on reducing the number of overdue incidents, with ward managers and specialist midwives leading on incidents related to their area or expertise. Additional training had been provided to ensure incidents were reviewed within a timely manner.

However, some action leads for specific incident reviews had reported they had not been notified of actions assigned to them. The service had completed a review of actions related to incidents and reported no outstanding actions were found to be presenting a significant risk.

During a period of leadership transition, the service used the Patient Safety Incident Response Framework (PSIRF) to identify themes and trends. The service now had senior maternity leadership established.

There was an identified risk around the lack of documentation and compliance regarding completing MEOWS and the service were waiting for the updated version of the early warning score to be added to the electronic notes system. The risk had been added to the maternity risk register, and a regular audit programme and an action plan to monitor compliance. However, senior leads during the inspection told us when completing a manual audit of MEOWs, staff compliance continued to be low.

There was a delay in women receiving an obstetric review within 14 hours of readmission to the postnatal ward. This meant there was a lack of timely and effective identification and management of ongoing health issues as well as an ongoing plan of care.

There were 138 maternity guidelines and documents, with 21 of those out of date and currently waiting a review. Senior leaders were aware of the out-of-date guidance and there was a dashboard to identify progress on updating guidance. Policies and guidance were uploaded to the trust intranet, and communication was shared with all staff.

Policies or guidance requiring immediate updates due to national guidance would be updated immediately. This meant any out-of-date guidance would still be in accordance with national guidance.

The service had a divisional maternity risk register. The top 3 risks were the second obstetric theatre due to the ventilation system not being adequate, the environment for triage and data quality following the implementation of the electronic notes system. Risks were prioritised, with mitigations, actions and review timeframes.

The service also reported on the maternity risk register, risks associated with some delays to the audit program. This failure to demonstrate sufficient progress against the saving babies lives care bundle could impact Clinical Negligence Scheme for Trusts (CNST) compliance. However, the trust had alternative assurance mechanisms, and the risk register noted delays in auditing may impact the ability to benchmark compliance. This meant there was a risk the service could be unable to be identify areas of poor performance, reducing their assurance that women and babies were receiving safe care.

The Trust’s risk register noted delays in auditing may impact the ability to benchmark compliance, with a risk being that the service would be unable to identify areas of poor performance. This reducing their assurance that women and babies were receiving safe care

The service had a governance structure which detailed the governance oversight and accountability from the service level to the trust board. Leaders operated an effective governance process and monitored key safety and performance through statistical process, with oversight and accountability from service level to the trust board. This was evidenced through the maternity dashboard.

We scored the service as 3. The service understood their duty to collaborate and work in partnership, so services work seamlessly for women

Leaders attended regular meetings with the LMNS to review governance and incidents and worked with the MNVP to contribute to decisions about care in maternity services. Meeting minutes showed current work being undertaken between the local MNVP, maternity service and the LMNS.

MNVP attended meetings with the maternity and neonatal safety champions and patient experience meetings were embedded into the service.

We scored the service as 3. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The service focused on continuous learning, innovation and improvement across the organisation and local systems. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for women. Staff actively contributed to safe, effective practice and research.

All staff we met were committed to learning and improving services. They had a good understanding of quality improvement tools and had the skills to use them. Leaders encouraged innovation and encouraged research.

There was a local training strategy which had been developed to achieve all elements of the core competency framework by the end of the training year. The perinatal quadrumvirate, trust board and the LMNS and integrated care board had oversight of the current education plan.

Learning was delivered in the clinical setting to ensure multidisciplinary teams receive emergency scenario training in a clinical area.

The service developed a maternity support worker (MSW) development programme across the LMNS. The MSW education lead had completed a train the trainer programme and was completing inhouse clinical skills training for band 2 and band 3 MSW’s. Following feedback from MSW’s the education team tailored a monthly bespoke training day to ensure they received updates on key knowledge and clinical skills.