The Care Quality Commission (CQC) inspected maternity services at Basildon University Hospital run by Mid and South Essex NHS Foundation Trust on 12 June 2020.
The unannounced, focused inspection was carried out to follow up on concerns raised by a whistle-blower regarding safety within the department.
The information received, and a subsequent review of the trust’s incident reports, showed that six serious incidents occurred in which babies were born in a poor condition and then transferred for cooling therapy in March and April 2020. Cooling therapy is a procedure offered as a treatment for such new-born babies. When such clusters of incidents are identified it is important to investigate them to identify any common causes and areas that could be improved to reduce the risk of further incidents.
During the focused inspection that followed, CQC found several concerns, including; high risk women giving birth in the low risk area, insufficient numbers of staff with the relevant skills and experience to keep women safe and provide the right care and treatment, and dysfunctional multidisciplinary team working which had impacted on the increased number of safety incidents reported.
Additionally, incidents were not always graded correctly according to the level of harm, lessons learnt were not always implemented and care records were not always securely stored.
Some examples of good practice were also found, including; infection risk was well managed, systems and processes to safely prescribe, administer, record and store medicines were effective, and managers regularly reviewed and adjusted staffing levels and skill mix.
Inspectors rated maternity services at Basildon University Hospital, as Inadequate overall. Maternity services were rated Inadequate for being safe, effective and well-led.
The department was previously rated Requires Improvement overall, following an inspection in February 2019.
CQC’s Chief Inspector of Hospitals, Professor Ted Baker, said:
“While inspectors found some areas of good practice, they also found a number of significant improvements were needed when they visited maternity services at Basildon University Hospital recently.
“Doctors, midwives and other healthcare professionals did not always work well together, and the absence of an open culture meant that staff did not always feel able to raise issues or report incidents so that learning could be effectively shared to help embed improvements.
“All staff we met during our inspection were welcoming, friendly and helpful. However, it was evident, that they were concerned about the recent cluster of serious incidents and wanted to improve the care they provided to women and babies.
“We have issued a warning notice requiring the trust to make urgent improvements to ensure mothers and babies are safe. The leadership team is clear about the steps they need to take and we will continue to monitor progress closely and will inspect again to check improvements have been made.
“Some of the concerns we found during this inspection – particularly those around the culture and leadership of the service - reflect wider themes featured in CQC’s recent briefing on improving safety in maternity services.
“We have seen some clear progress made by NHS maternity services since our first round of comprehensive inspections, but we are still seeing too much variation in quality and safety across the country. We cannot afford to be complacent and it is vital that services continue in their efforts at pace to ensure that all women have access to safe, effective and personalised care wherever they live.”
Following the inspection, CQC issued a warning notice to the trust identifying the specific areas where improvements must be made with a compliance date for 14 August 2020. The trust initiated an immediate action improvement plan which inspectors have been closely reviewing.