City Hospital

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• 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

We heard that communication was sometimes an issue, and we found policy was not always followed in relation to translation services, with availability of interpreters sometimes being a problem and examples seen when family members had been used. The MBRRACE-UK perinatal mortality report 2022 births highlighted stable and adjusted mortality rate excluding deaths due to congenital anomalies was more than 5% higher than the average for similar trusts and had been for the last 3 years. Reports showed trust targets were not met in areas such as the initial triage assessment, ongoing midwifery and medical care. Findings from reviews showed that admissions to the neonatal unit could have been managed on the transitional care unit or avoided with enhanced transitional care and support services. However, women were positive about pain management. There was lots of work being completed by the equality and diversity team. Staff told us about how they used flash cards to communicate with people who were deaf or who had a learning disability. Pocket guidelines had been produced for people living with anxiety, deafness, blindness and those who identified as trans or non-binary. The service ran specialist antenatal clinics based on maternal need such as diabetes and epilepsy. The service had also carried out various quality improvement projects, been involved in peer reviews and benchmarked themselves against other hospitals.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Women reported they had been given a choice about what type of pain relief they wanted, and that they were given pain relief when they requested it. Feedback from CQC’s Maternity Survey 2023 (published February 2024) showed women and birthing people rated pain management during birth, and then after birth, about the same as women and birthing people who used other trusts. We heard communication was sometimes an issue, for example blood test results were not always fed back to women in a timely way and they had to chase this information. One woman who did not speak English and had attended with a family member told us that sometimes they had an interpreter booked, sometimes language line was used, or sometimes they were asked to bring a family member for translation which was not in line with policy. They told us availability of interpreters was sometimes a problem, and this made some interactions difficult. However, feedback from CQC’s Maternity Survey 2023 showed women and birthing people rated clear communication about the same as users of other services. Overall, most of the women we asked said that they were satisfied with their care.

Staff recorded the needs and preferences of women and birthing people on the electronic recording system. Staff commented that the diverse workforce meant many staff could speak to service users in their first language. Staff spoke about flash cards they had used to communicate with women and birthing people who were deaf or had a learning disability. They also told us how they had been trying to introduce discharge videos in different languages on the postnatal ward for several years but felt this “wasn’t a priority” for the service. The lead midwife for equality, diversity and inclusion explained they had introduced a video link interpreting application on 10 tablets on wheels, but these were not always used as intended. They were working to implement an interpretation system for triage that would mean that women and birthing people could be connected to triage via an interpreter. They told us that they had produced ‘pocket guidelines’ for use with women and birthing people living with anxiety, deafness, blindness, and those who identified as trans or non-binary. They stated that one of the main barriers to this project was the cost of printing. We were told that financial need could be a barrier to some women and birthing people attending their appointments, and so they had worked with a local bus company to provide 800 codes for free travel, although the limitation was access to a smartphone. Leaders told us the service ran specialist antenatal clinics based on maternal need including diabetes, epilepsy, hypertension, maternal infection and out of area bookings. Staff told us that they discussed pain relief choices with women and birthing people. One midwife said that doctors may “push for an epidural”, but they would try to explain all of the available options.

There was a policy in place for caring for expectant and birthing women or people with a learning disability and/or autism which was in date, comprehensive and incorporated national guidelines, as well as a comprehensive care of the trans & non-binary expectant & birthing person policy, however, this policy was not dated. We reviewed the equality and inclusion pocket guide produced by the equality and diversity team. It contained information for staff on checking for cyanosis and jaundice on darker skins, recognising mastitis and c-section site infection in women with dark skin, and information and links to support for asylum seekers, refugees and new migrants. It also contained comprehensive information on how to access interpretation services, including face-to-face British Sign Language interpreters. Furthermore, the guide contained information on how to support the hearing-impaired, visually impaired or physically disabled person, and women and birthing people living with learning disabilities. There was guidance on supporting LGBTQ+ people, people experiencing high levels of anxiety in addition to links to local authority and voluntary sector support services. However, in a review of 18 perinatal mortality review tools from the period between January and July 2024, the use of family members as interpreters during labour and birth was noted in 2, and the use of family members during antenatal care noted in another which did not represent best practice. Furthermore, in a review of care records on 28 June 2024, it was recorded that a woman spoke Punjabi as their first language; however, they were not offered interpretation services during their care, instead her husband, and where available, clinicians who spoke her language, were used.

We did not look at Delivering evidence-based care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

During the on-site assessment we found that overall, most women said that they were satisfied with the outcomes of their care.

Leaders spoke about the audits of induction of labour pathways against induction guidelines. They told us they audited 20 sets of notes per month and in doing so had found some high-risk women and birthing people were being given propress without consultant review beforehand. They said that this learning had been fed back to staff who were reminded of the process. Staff also discussed an improvement project that was being carried out to look at ways to reduce delays around medication to take out. One staff member said they would be keen to carry out an audit of telephone calls on their ward as they spent a lot of time taking calls each day and often did not have ward clerk support.

Information about people’s care was routinely collected and monitored. For example, we saw in the Maternity and Neonatal quality report (May 2024) that perinatal mortality data for April had been reported on. There was also evidence that other information was collected and monitored including Robson categorisation, newborn screening and red flags. The service had carried out various quality improvement projects and audits. For example, there had been a major obstetric haemorrhage audit completed in 2023, a re audit on enhanced recovery in obstetric surgery as well as an introduction to obstetric review on the service electronic notes system. The projects identified areas for improvement and made recommendations to improve outcomes. The service completed audits with the aim of improving outcomes, those completed included fresh eyes, red flags and triage. The service benchmarked itself against other hospitals. We saw some slides titled Reviewing National Maternity Dashboard Data for the Local Maternity and Neonatal System. Areas benchmarked included bookings data, ethnicity and deprivation, smoking data, 3rd and 4th degree tears and post-partum haemorrhage. We saw that a peer review of the maternity departments had been completed in April 2023 and that a summary of recommendations and areas of improvement had been identified within the report. The service collected data on births and readmissions. They also used key performance indicators to measure performance in areas such as timeliness of antenatal screening and avoidable repeat tests.

The MBRRACE-UK perinatal mortality report: 2022 births highlighted stable & adjusted mortality rate excluding deaths due to congenital anomalies was 0.89 per 1,000 live births; as more than 5% higher than the average for similar Trusts. The stabilised & adjusted neonatal mortality rate had been more than 5% higher than the average for each of the last three years. The service was working with other organisations following emerging themes resulting in patient safety issues and poor outcomes. There was an action plan in place to address these concerns which was reported on in the most recent Maternity and Neonatal quality report. The CCQ maternity Survey 2023 showed the trust compared about the same as other trusts in relation to labour and birth, staff caring for you and care in hospital after birth. The service had compared the results to the previous maternity survey and identified actions to improve. The triage report December to May 2024 showed trust targets were not met in areas such as the initial triage assessment, ongoing midwifery care and ongoing medical care. We reviewed the report Saving babies lives January 2024 to March 2024. The service passed each element 1 to 6 at 70% or above. We noted the service had reported poor outcome for two cases following postponement in induction of labour at 41+6 weeks. Findings noted in a quarterly report dated January 2024 to March 2024 included 11 admissions in this time period could have been managed on the current transitional care unit (TCU), 13 additional admissions could have been avoided with enhanced TCU and support services. Patient Safety Incident Response Framework data showed the main themes as being unexpected transfer to the neonatal unit (17), communication failure with social care (14) and incorrectly filed notes and consent incomplete/missing (10).

We did not look at Consent to care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.