A CQC Inspection took place at Nottingham University Hospitals ( NUH ) maternity services in April.
On 25 and 26 April 2023, the Care Quality Commission undertook an inspection of maternity services at City Hospital and Queen’s Medical Centre.
Early feedback from the inspection, which noted some improvements, including, observations that care was being delivered with compassion, good feedback had been received from women and progress in relation to staffing levels.
NUH said that ‘Some areas of concern were also highlighted, and a response was provided to CQC, which outlined action taken to immediately address items including, PAT testing of electrical equipment, resuscitation trolley security and medicines management.
‘We continue to respond proactively to further requests for information, during this inspection process.’
The following comes from NUH Board Papers for a meeting being held on Thursday 11 May.
Communications and Engagement
- 11 ‘roadmap’ display boards have been installed across City and QMC campuses, within maternity ward areas; these are to support both staff and the public to see the improvement journey ‘at a glance’, over the past two years.
- The staff intranet pages and the regular email newsletter for staff have been redeveloped to help raise awareness and levels of engagement with improvement work. A staff survey about the MIP was taken in early 2023 and will be re-run in June 2023 to test the impact of these and other interventions. The baseline survey told us that staff prefer to receive electronic information via social media and the intranet, and showed we had room to improve how involved staff feel with the MIP, and how confident they would be to talk about improvements to others.
- On 6th April 2023, the Chief Nurse and Director of Midwifery led a maternity- focused, ‘Ask the Exec’ engagement session, which attracted more than 250 attendees from across the Trust. Key messages included the investment in services and recruitment and retention, and demonstration of the way outcomes are improving. During the session, staff had the opportunity to ask questions.
Postnatal care pathways
- The service is now using an improved process for TTOs (medicines to take out) prescribed in theatre for elective Caesarean section cases. Positive feedback has been received from both staff and service users, and early data demonstrates that this has improved the discharge process by an average of two hours.
- Midwife-led discharge, following uncomplicated elective Caesarean section, has been implemented in practice with the support of a newly approved SOP (Standard Operating Procedure). This has the aim of facilitating timely discharge for women from the acute areas, when safe to do so.
- A discharge information video for women and birthing people has been produced in conjunction with Nottingham Trent University; final comments have been received with sign-off from the Director of Midwifery. These are now underway with a function of subtitles that will support a wide variety of languages.
- In response to performance data, designated Newborn and Infant Physical Examination (NIPE) trained Midwives are now rostered into the acute areas with appropriate equipment, with further work ongoing.
- Following an assurance assessment of the CQC Must and Should do actions and ongoing engagement with staff and women, the new priority areas of work agreed for Quarter 1 have been identified. These have been agreed by the Family Health Divisional Leadership Team (DLT) and the Maternity Improvement & Assurance Board.
The key priority areas for Q1 will be:
- Training – completing a Training Needs Analysis (TNA) and increasing mandatory training compliance towards the 90% target with a focus on Safeguarding
- Observations and escalation – to review the clinical guidelines relevant to observations and align to appropriate Nervecentre pathways, taking into account the findings of Dr Lucy Blanks’ survey Staff Perceptions of Handover and Escalation Practices (Feb 2023)
- Medicines management – to review the arrangements for the management and oversight of medicines across the service including audit processes, and plan for the required clean utility minor works
• Governance actions – continuing to develop and embed from Q4 the QRS Framework (to be in place by August 2023), process for reviewing clinical guidelines, developing the SI process and learning from when things go wrong; these larger pieces of work are expected to continue into Q2 2023-24.
The following additional areas will also remain active during this sprint:
- Options for reinstating a Homebirths service
- Continuation of the postnatal pathway work to look at Enhanced Recovery
- Antenatal services and ultrasound capacity
Any remaining actions not fully completed during Q4 will continue across the next sprint; this comprises the ongoing elements of Postnatal Care Pathway improvement and some Governance actions which were postponed to support the completion of outstanding Serious Incident (SI) investigations.
4. MATERNITY SERIOUS INCIDENTS (SI)
A recovery plan has been carried out to ensure that all outstanding serious incidents declared prior to September 2022 have been reviewed. Actions have been drafted against all recommendations and a consolidated action tracker developed to enable progress to be monitored. As of 31st March, two cases from this cohort remained open; comprising one case awaiting an external HSIB (Healthcare Safety Investigation Branch) report and one investigation report which is with the family for their own review. These cases are a high priority, with expected closure to be achieved by the end of May 2023, however external investigation does not allow full control over the timeline.
In order to improve the management of SIs and reduce the likelihood of future outstanding cases, two whole time equivalent (WTE) SI lead reviewer posts are being recruited, to supplement the team and offer support to clinicians. Recruitment to these roles is anticipated to take around three months and will be managed by the Quality and Patient Safety Team, followed by three months of training.
The Maternity Service has been working on a ‘bridging’ proposal for progressing SIs between April 2023 and November 2023, this will aim to increase capacity and offer additional training and development. It will also contain plans to further improve our SI processes and family liaison.
INDEPENDENT REVIEW OF MATERNITY SERVICES
We continue to fully cooperate with the review into Maternity Services at NUH, which is being undertaken by Mrs Donna Ockenden. A regular Learning & Improvement meeting has been established, which allows us to share and learn from case reviews and engagement with women and families in a timely way. Following the last meeting, we heard that:
- 1) Local families, who may be ‘hard to reach’, do not always feel heard and there is a lack of continuity with information sharing, particularly in Urdu clinics.
- 2) Concerns have been relayed from some maternity staff about a proposal to change the length of clinic time accompanied by an Urdu language interpreter.
- 3) Women have raised a lack of availability of interpreting services within the Trust. There have been some issues with telephone provision for interpretation.
- 4) The review team have been advised that there is no written information in Urdu.
- 5) Local women have reported instances of male sonographers being allocated to
the care of Muslim women. There have been incidences where female sonographers have not been available.
We are keen to act on this feedback in the most proactive way possible. We have therefore acted immediately on the length of clinics and have asked the Director of Midwifery to instigate a Taskforce, to address the specific areas raised by Mrs Ockenden. The full detail of the letter has been discussed with the ICB and will be shared with the MVP and LMNS, as much of this work will benefit from a system-wide approach.
7. CONCLUSION
In summary, the report has outlined the key developments within Maternity Services and progress with making improvements against the Improvement Plan.
Good progress has been made with actions across Q4 2022-23 and this will continue to be embedded, alongside the delivery of work against new priorities.
Fundamentally, these activities continue to support the delivery of safe, high quality care and the continued focus on engaging with families and learning from their experiences.
