The Care Quality Commission (CQC) has taken urgent action to keep people safe following an unannounced focused inspection of maternity services at the Jessop Wing run by Sheffield Teaching Hospitals NHS Foundation Trust.
The inspection in March was prompted following concerns about the safety and quality of services being provided to women and babies.
This inspection sees the overall rating for maternity services at the trust drop from outstanding to inadequate. Urgent conditions were imposed on the trust requiring them to take action to ensure the safety of patients using these services and to regularly report to CQC on the progress made.
The service was also rated inadequate for being safe and well-led, requires improvement for being effective. Responsive and caring were not rated at this inspection.
Sarah Dronsfield, CQC’s head of hospital inspection, said:
“When we visited maternity services in the Jessop Wing at Sheffield Teaching Hospitals NHS Foundation Trust, inspectors found a service that was not providing the standard of care women should be able to expect. Our findings were such that the ratings for maternity services across the trust have moved from outstanding to inadequate.
“Due to the concerns we found that needed addressing as a priority, we have imposed urgent conditions on the trust’s registration which require immediate action in order to make sure people receive the care they are entitled to.
“However, we also found some areas of good practice and a culture where staff felt respected, valued and supported. Staff were caring and focused on the needs of the women receiving care, and the service also promoted equality and diversity in daily work.
“Following the inspection, the trust has provided an action plan detailing what they are doing to reduce these risks and we have discussed the first stages of the improvements the trust has taken. We continue to monitor the trust extremely closely and expect them to continue to make rapid improvements.
“The trust leadership team know what they must do to improve patient safety and we will re-inspect to ensure this happens, taking further action if needed to protect patients.”
Inspectors visited the labour ward, two postnatal wards, antenatal ward, admission triage area and the advanced obstetric care unit. They also spoke to staff and observed them providing care and treatment to patients.
Findings from the inspection included:
- The trust did not have effective systems in place to ensure that staff had the skills, competence, knowledge and experience to safely care for women and their babies
- The trust did not have effective systems in place for managing and responding to patient risk to ensure all mothers and babies who attend the unit are cared for in a safe and effective manner and in line with national guidance
- Staff did not always complete and update risk assessments for each patient or take timely action to minimise and mitigate risks
- Patient safety incidents were not always managed well. There were delays in the investigation of incidents and lessons learned were not always shared with the wider team
- Records were held on multiple systems and staff had to access different systems to obtain a full overview of patients notes which could put patients at risk.
The urgent conditions demand that the trust must make several improvements, including:
- Ensure systems are put into place so that staffing is actively assessed, reviewed and escalated appropriately to prevent exposing women and babies to the risk of harm
- Ensure systems are put in place so staff are suitably qualified, skilled and competent to care for and meet the needs of women and babies
- Ensure effective risk and governance systems are implemented to support safe care
- Improve monitoring the effectiveness of care and treatment provided to patients
- Ensure risk assessments and risk management plans are completed in accordance with national guidance and local trust policy and documented appropriately
- Correct processes are in place for investigating serious incidents that reduce delays and accuracy of investigations
- Improve lessons learned and the sharing of lessons learned among the whole team and the wider service
- Ensure all staff are competent for their roles
- Improve infection prevention and control
- Ensure safe systems and processes to prescribe, administer, record and store medicines are in place and applied.
Full details of the inspection are given in the report published on our website.
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