St James's University Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective - this means we looked for evidence that people's care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence. At our last inspection we rated this key question Requires Improvement.

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This service scored 58 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service was working towards maximising the effectiveness of people's care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

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Women were assessed and their care prioritised using a red, amber, green scale. Generic risk management plans available, and personalised specific to women's needs such as pre-eclampsia and reduced fetal movements were used. We received mixed patient feedback about how patient needs were assessed. Some patients told us they did not feel their needs were listened to with compassion and understanding when they called the service for advice and help. Others told us they were not assessed with kindness and compassion when they attended the service. People told us they were reluctant or uncomfortable to return to the maternity assessment centre (MAC) because of the way some staff had made them feel, whilst others told us they had delayed their return despite having concerns for their own wellbeing. This increased the risk to patients and unborn babies because it meant people did not always seek support when needed due to concerns about being dismissed.

From patient feedback we found that patients did not always feel as involved in decisions as they would like to be because staff were busy and there was not always time for detailed discussions.

Community midwifery staff told us they provided additional support for pregnant teenagers, and pregnant people from marginalised communities such as those whose first language was not English. We were also provided with an example of care and support delivered to people with a learning disability who were supported to make decisions about antenatal, delivery and postnatal support which met their specific needs.

We observed midwifery and medical staff work together to make sure patients were assessed in a timely way despite the operational challenges and the conflicting priorities of staff on the wards.

The service planned and delivered people’s care and treatment with them and in line with legislation and current evidence-based good practice and standards.

The Trust used a storage system for all clinical guidelines and pathways called Leeds Health Pathways. This system was used for primary and secondary care throughout Leeds and allowed all staff to search for guidelines and view them electronically using PCs or mobile devices. Staff were encouraged to view these documents electronically to ensure that the latest version was being accessed.

Services were delivered in line with both National Institute for Health and Care Excellence (NICE) and The Royal College of Obstetricians and Gynaecologists (RCOG) guidelines. We saw that staff could access both internal and external guidelines and standard operating procedures easily online.

Escalation protocols were clearly displayed and when we reviewed maternity related policies, we found these were regularly reviewed by appropriate clinicians and based upon up-to-date evidence based practice.

Staff told us they were encouraged to enhance their clinical practice by attending national events such as conferences however they also expressed that this was sometimes difficult due to staffing pressures. Staff were also encouraged to work innovatively and recently the Preterm Midwifery team had won national awards for their work on early access to maternal breastmilk and improving screening for sexually transmitted infections that increase the risk to preterm births. They had also established a national network for preterm midwives.

The service worked effectively across teams and services to support people, making sure they only needed to tell their story once by sharing their assessment of needs when they move through their birthing journey.

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Staff we spoke with told us that teams worked well together and that due to midwives rotating across different wards and departments within maternity services staff had a good understanding of the work of each team.

Staff had access to the information they need to appropriately assess, plan and deliver people's care, treatment and support using electronic records.

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Plans for transition, referral and discharge considered people's individual needs, circumstances, ongoing care arrangements and expected outcomes. Despite staffing challenges, when people were due to move between services, all necessary staff, teams and services were involved in assessing their needs to maintain continuity of care. Information was shared between teams and services to ensure continuity of care, for example when clinical tasks were delegated or when people were referred between services due to additional health needs.

When people received care from a range of different staff, teams or services, it was co-ordinated effectively. Relevant staff, teams and services were involved in assessing, planning and delivering people's care and treatment and staff worked collaboratively to understand and meet people's needs.

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We reviewed a suite of detailed standard operating procedures (SOP) owned by The West Yorkshire Association of Acute Trusts who worked together as a collaboration which brings together local NHS Trusts to give patients access to the most appropriate facilities. SOPS's included but were not limited to elective treatment access protocols.

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Safeguarding specialist midwives attended multi-disciplinary meetings with lead agencies including the local authority and others where appropriate to discuss current safeguarding concerns such as child sexual exploitation as well as policy updates.

The service supported people to manage their health and wellbeing so they could maximise their independence, choice and control, live healthier lives and where possible, reduce their future needs for care and support.

Community midwives worked with birthing people to support them to lead healthier lives during pregnancy including delivering support for healthy eating, reducing and stopping alcohol and drug intake, and stopping smoking. Staff assessed each woman’s health at every appointment and supported individual needs.

Wards and units also had differing information available for mothers to help them to make informed choices. There were posters and leaflets on how to keep healthy and keep babies safe and well. For example, we saw easy read posters encouraging women to stop smoking and the importance of healthy eating. Staff gave women practical support and advice to lead healthier lives.

The service considered the mental health and wellbeing of people and there was a psychology service within the unit that was accessible to both staff, parents and siblings as and when required.

Women had access to information from using their own maternity electronic notes via an electronic device. Resource sheets were available which included information on telephone help lines, websites, and apps.

Staff were trained to support women with newborn infant feeding. Mothers requiring additional support were identified through routine post-natal care and information was documented in the post-natal notes. Breastfeeding women were signposted to local breastfeeding charities and leaflets were available.

The service routinely monitored women's care and treatment to continuously improve it and to ensure that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The service had developed an annual clinical audit programme based on national, local and incident specific requirements. Some staff told us that audits were often nurse specific so not always relevant to midwifery. Clinical audits identified when staff were not following guidelines and action plans were used to support staff to improve their compliance.

The service also monitored documentation completion monthly. This included checking whether staff were completing observations and early warning scores such as sepsis screening and domestic violence risks in a timely manner.

The organisation submitted performance information to Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK). NHS England carried out multiprofessional and midwifery led clinical audits covering a wide range of subjects for example HIV in pregnancy, postnatal bladder care, epilepsy and pregnancy and sepsis documentation and management.

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The department also used dashboards to monitor key performance indicators (KPIs) such as timeliness of interventions, statistics about different methods of delivery, antenatal screening, timeliness of scanning, public health information such as smoking and alcohol status, breastfeeding information and preterm births. This information was analysed and used to inform ways to improve patient outcomes. KPI results showed most carried out met the acceptable threshold. However, some performance was below Trust target such as for avoidable repeat tests scoring 3.4% against a target of 2%.

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We reviewed the latest documentation audit scores dated January 2025 and saw the antenatal inpatient unit scored 77%, with 9 areas for improvement. Lowest areas of compliance included but were not limited to, induction of labour, pressure area care, smoking assessment fundal height plotting. Delivery suite documentation score for August 2024 scored 89% and showed areas of improvement included recording of pain scores, pressure areas, urine output and cannula, catheter and venflon monitoring. Audit results were fed back to wards at team meetings with reminders of specific areas to be vigilant of.

The service used a weekly risk tracker to review patient safety incident concerns. We reviewed the tracker dated 30th January 2025 and saw it recorded only basic information with no dates for action or review. This corroborated our concerns in relation to the robust management of incidents and the lack of development by the service to triangulate concerns to prevent further incidents.

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We also reviewed the latest response times for the provision of epidural audits dated December 2024 and saw the service fell slightly below the Trusts own target of 80% scoring 77% where patients attended 30 minutes from request of epidural. Recommendations included communication and training, delay analysis, improving recording systems and continued re-audits to monitor for improvements.

The service told people about their rights around consent and respected these when they delivered person-centred care and treatment.

We reviewed the service policy in relation to consent to examination and treatment policy and saw it was in date and had been reviewed. All Trust staff were required to refer to and follow this policy and guidance when proposing to provide care and treatment. All valid consent was to be obtained prior to any care or treatment and be discussed as routine practice, where possible, with families present.

As part of medical staff induction process all FY1 and FY2 trainees were required to complete a consent learning module. Trust policy states any member of staff required to obtain consent must also be trained in the clinical setting under supervision of a consultant who performs that procedure. However, some medical staff told us they did not receive protected time to complete all induction training, and the service did not have oversight of compliance of completed consent modules as part of the mandatory training monitoring. The Trust did not include consent training as mandatory for midwifery staff and the information sent to us by the Trust relating to training compliance did not include consent training compliance for any staff, including medical staff. This posed the risk that staff who were not suitably trained were obtaining consent from patients.

All records we reviewed however, showed consent process had been appropriately followed but we could not be assured the person taking the consent has undergone the training required to do so.