City Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Staff gave mixed feedback around the learning culture in the service. Opportunities for learning were not always recognised or embedded. Women and birthing people did not always receive care in line with national guidance and documentation was not always completed to the required standards. Not all labouring women and birthing people received 1:1 care in labour, there were delays with induction of labour. The trust did not adhere to triage prioritisation. Staff felt safeguarding was sometimes pushed aside due to time constraints. Audit data showed that compliance with fresh eyes was low and, in some cases, not calculated. Staff told us how they felt the environment was cramped and spoke of shortages of some equipment. We found out of date stock on the antenatal ward and that emergency equipment checks were not always completed. The sub waiting room in triage lacked oversight. Staffing and skill mix was not in line with good practice. Partograms to identify concerns during pregnancy loss were not always completed. Staff were not always appropriately trained. The service continued to be an outlier for perinatal loss. However, the service sought patient feedback and tried to use the results to improve. Partners provided mainly positive feedback, they felt the trust was open and transparent and that they provided them with the relevant information. Daily safety huddles took place. Staff were aware of escalation pathways. We found risk factors were recorded consistently in patient records, risk assessments were mainly recorded for each appointment and there was evidence of onward referrals when needed. Labour ward documentation audits showed an excellent standard.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a local midwifery patient experience group in addition to a family and friends’ group to gather feedback on patient experience. We found that one patient’s experience was that they had felt alone and isolated due to their specific dietary requirements. In response, the trust were looking at the use of volunteers, providing different food options as well as having a freezer on site. The department sought Friends and Family feedback in relation to births. Positive themes included staff attitude and implementation of care. Negative themes included environment and implementation of care. Positive themes on the antenatal ward included staff attitude and environment, negative themes were staff attitude and communication. A Healthwatch report from 2023 had looked at the experiences of 28 Black African and Black Caribbean Women, which the trust did not consider representative of the department numbers and found participants wanted to see improved access to information and advice, continuity of care as well as improved support for those with underlying conditions or co-morbidities and concerns. They told us that the trust equality and diversity midwife had worked with voluntary groups to improve engagement and perspectives as well as completing "you said, we did" boards. Patient experience feedback that had been recorded in safety briefings suggested improvements such as avoiding using medical terminology and informing them of delays.

Staff gave mixed feedback about the learning culture. For example, one staff member told us they received a lot of input from the hospital risk team as well as receiving feedback on the incidents they reported. Others told us they occasionally received feedback about incidents they were involved with but rarely heard about incidents which had occurred on other wards; that they did not receive a clear answer when asking for follow up information on incidents; that there was a lack of transparency around deaths and incidents and that they felt things were “swept under the carpet”. Feedback from the trust’s most recent quarterly staff survey in response to the statement “We are always learning”, which also included continous professional development and other development activities was that 66% of staff in maternity and perinatal medicine responded positively, while 16% responded negatively and 18% neither agreed nor disagreed with the statement. Leaders recognised that in the past incidents had not always been escalated through the designated pathway but were embedding this in the new leadership team. Leaders were aware that there was a lack of partogram use, particularly with perinatal loss as it had been identified in previous themes.

Opportunities for learning were not always recognised or embedded in the service. Our review of perinatal mortality review tools (PMRTs) demonstrated they had not always been completed to the required standard. We escalated several care concerns noted in PMRT’s including neonatal resuscitation not being undertaken in line with national guidelines, and partograms not being completed for women experiencing pregnancy loss. The service were frequently an outlier for perinatal loss and stillbirth since 2021 being 5% higher than other trusts and higher than the expected national loss rates. A thematic analysis had been undertaken by NHS Resolution. The analysis was taking place due to a higher than national average incidence rate of early notification (EN) cases from 2018 onwards, with more than twice the national average in 2020/2021. Themes found included issues requesting foetal growth scans, delay in escalation from maternity triage, delays in delivery and escalation, lack of escalation of abnormal foetal heart rates, an action plan was in place based upon the findings. Saving babies lives Q4 report dashboard from January to March 2024 showed several areas were red and did not meet the target rates. Fresh eyes audit completion rates remained low despite regular audits. However, the trust sought patient feedback, discussed it in various forums and tried to use the results to improve. The service shared information in relation to identified learning in the local maternity and neonatal system meetings. Some processes were in place to monitor complaint themes and trends. We reviewed a serious incident report and found duty of candour to be reported on. The service had completed a pilot supporting access into maternity services in response to listening to families from ethnically diverse backgrounds. The service compared the results of the most recent CQC maternity Survey 2023 to the previous one and identified areas to improve. what actions were needed to improve.

We spoke to 2 people about triage as part of our assessment. One woman who had been admitted via triage said she had not encountered any problems and had been assessed within 20 minutes of arrival. A family member we spoke with described a poor experience with the triage pathway, stating that staff did not look at their family member’s notes when attending. However, we understand that the small sample size may mean this is not representative of all women.

Staff were concerned about the induction of labour pathway. They told us that prior to June 2023, only low-risk inductions of labour were undertaken by midwives on the antenatal ward, and that most took place on a specialised induction suite. However, staff told us that all inductions were moved overnight onto the antenatal ward without appropriate risk assessments. Staff also told us the antenatal ward was the most unsafe area in the service due to staffing levels and acuity and how they felt the pathway was dangerous due so many inductions being started at once. They spoke of how the sudden change to the induction of labour pathway and that women regularly waited 3-4 days once admitted to the ward for induction of labour to be commenced. They also felt that waiting for review by a doctor was a source of some of the delays. Leaders acknowledged that the decision to move the inductions of labour to the antenatal ward was rushed and was a priority for the new leadership team to address. They also adjusted the criteria for induction on the ward so that the highest risk women and birthing people were induced on labour ward. Leaders recognised that the trust guidelines on post-dates induction of labour did not meet NICE guidance. Leaders also told us that there was a daily slot in place for elective caesarean sections, and due to a separate theatre team performing this list, these operations were very rarely cancelled. However, we were told that there was not a second theatre team immediately available for use out of hours, and when required, a team would be called in from home which could cause delays to treatment. There were 2 red flag incidents relating to theatre delays in the 6 months prior to the inspection.

Partners provided us with mainly positive feedback in relation to the trust. They felt the trust was open and transparent and that they provided them with relevant information. They told us how they had done their own reviews and were aware of the challenges faced by the trust, such as workforce and culture which they felt the trust had worked proactively to address. They also spoke of how the trust received a lot of the very new immigrants into the country due to their location who may not have received any previous antenatal care. Partners also told us how they were confident the trust would take action when areas of concern were identified and were able to share areas, they felt the trust needed to improve. They were aware of the equality and diversity midwife and their role within the service. They told us how feedback from patients had included not letting partners stay postnatally and women being left to their own devices which could be quite traumatic. They also gave examples of how processes had been changed as a result of certain feedback .

Induction of labour guidelines did not meet national guidance. There were delays to the induction of labour, which led to poor outcomes for women, birthing people and babies. Some policies were out of date. Data provided by the trusts delayed induction tracker showed delays in the induction of labour up to 144 hours between 13 March and 18 June 2024. The service did not use a standardised clinical assessment tool, the trust induction guideline categorised induction of labour according to risk status. However, plans were in place to introduce a recognised risk assessment tool in July and fully implementing standardised practice by the end of September 2024. We reviewed and saw evidence of the service failing to provide 1:1 care in accordance with national guidelines and is a red flag when 1 midwife is not able to provide this 1:1 care and support to a woman during labour. The service did not have an operational structure and pathways to support safe care of pregnant women outside of scheduled appointments. The trust did not adhere to triage prioritisation. Data showed the number of women and birthing people who were initially assessed within 15 minutes was not in line with good practice. Compliance rates in the commencement of ongoing midwifery care for women was low and in most of the data provided, the service was unable to calculate compliance with triage guidelines. Daily safety huddles took place which included areas such as patients needing urgent review, discharges and patient flow. The trust reported on areas of key quality and safety which fed into the quality committee. This included current risks, incident themes and trends, audits and safety recommendations following serious incidents.

We did not ask women or birthing people any specific questions around safeguarding during the on-site assessment as we did not speak to anyone who needed safeguarding at the time. However, feedback from CQC’s 2023 Maternity Survey (published in February 2024), showed that women and birthing people rated raising concerns, that is staff taking concerns seriously once raised, about the same as service users of other trust.

Staff told us that due to the complex needs of the population, they dealt with a lot of safeguarding issues in the service. Staff and students were able to identify safeguarding concerns and give examples of cases they had dealt with. They told us that the current safeguarding team were not always able to support them however, and that they took on tasks such as attending discharge planning meetings on top of their clinical workloads. Some staff told us how they felt safeguarding was sometimes “pushed aside” and not given due attention by staff due to time constraints.

Staff undertook safeguarding training as part of their mandatory learning. However, compliance rates for Safeguarding Adults Level 3, Safeguarding Children Level 2 and Safeguarding Children Level 3 were not within the trust’s target levels of 90%. The service had policies in place for the safeguarding and protection of adults and children at risk and female genital mutilation, which were comprehensive and in date. There were also guidelines in place to follow after a missing baby or child alert in the inpatient area, and for supervision of children. These guidelines were comprehensive but were not within review dates of May 2023 and May 2024 respectively at the time of the assessment. The trust were in the process of developing a new domestic abuse policy. The safeguarding team had a duty rota in place for taking advice calls from staff. In the period from January to March 2024, 166 calls were made to the team. We saw appropriate actions had been taken by staff following disclosure around female genital mutation (FGM). However, we also noted that despite disclosure of FGM, examinations were not recorded correctly. In some of the records, routine enquiries regarding domestic abuse were not always recorded as being asked, often because a partner or other relative was present, but sometimes the rationale was not recorded. In one record, routine enquiries were not made until 38 weeks of pregnancy, and in another, not until 29 weeks of pregnancy.

Most women felt that the risks associated with different care choices had been explained to them by staff. However, 1 woman told us that she was not aware she had a caesarean section until she took a shower 2 days after giving birth as it had not been communicated to her. Another woman felt that her birth plan had not been taken into consideration when she was induced. Feedback from CQC’s maternity survey 2023 showed women and birthing people rated the advice given on both the risks and benefits of induction and the decision to be induced about the same as service users of other trusts. Advice given at the start of labour was also rated about the same as other trusts, however partner involvement during labour and birth was rated somewhat worse than expected. Delays to discharge were rated better than expected.

Staff were aware of escalation pathways. They told us how the Band 7 co-ordinator on duty had remote access to cardiotocography traces and could provide advice when needed, and they had no issues getting help when concerned, including at night. A midwife we spoke with about a recent emergency with stated that the team “came together well”. A student midwife said they would like to see more training around emergencies as they felt they were “learning in the moment”. Leaders recognised that inductions of labour on the antenatal ward were a high-risk area and were reassessing guidelines to reduce risk. They also noted concerns around fresh eyes compliance and stated that they needed to work on ‘professional curiosity’. Leaders told us the ‘Serenity’ midwife led unit had been closing and re-opening since Autumn 2023, due to concerns that the unit could not be safely staffed. Leaders also recognised that before this point there had been too many higher-risk births going to the unit and subsequently too many babies being transferred to the neonatal unit, and criteria for admission to the unit had been changed. Leaders told us how midwife-led care was still being delivered where appropriate on labour ward, and that midwifery-led care was an ‘ethos’, rather than being location dependent. Re-opening the unit was based on risk assessment and the service’s business continuity plan. A senior midwife told us staffing was assessed on a weekly basis to inform whether it was safe to open Serenity unit, and a standard operating procedure had been drafted. They told us that communications were in place to ensure women and birthing people were aware of the disruption to the service. However, midwives did not always feel that the closure of Serenity unit was well-communicated to women and birthing people.

Patient records showed and risk factors were recorded consistently. However, there was no formal section for recording of deprivation. We did not see evidence of red, orange, yellow or green prioritisation of women attending triage recorded in the attendance book and/or board. However, records showed risk assessments were mainly recorded for each appointment, including onward referrals when needed. Questions around foetal movements were consistently recorded, and foetal growth was consistently plotted on personalised growth charts. In care records checked Modified Early Obstetric Warning Scores (MEOWS) were completed, scored and escalated when required. We reviewed whether fresh eyes of cardiotocography (CTGs) had been undertaken in records and found it had been completed as required. However, audit data showed compliance with fresh eyes was low and, in some cases, not calculated. We found aspirin provision was inconsistent, with some women struggling to access this from their GP, and another woman being told to access medication through triage. There was a process being finalised to allow community midwives to supply aspirin. We reviewed a sample of labour ward documentation audits carried out between January and June 2024. In most audits we reviewed, all aspects were graded ‘A’, that is to an excellent standard. Handovers were found to be comprehensive with clear evidence of reflection and learning. We reviewed evidence of a ‘skills drill’ from April 2024. There was clear evidence of reflection on the drill, and learning points which were discussed during a feedback session. We reviewed 18 Perinatal Mortality Review Tools from the period between January and July 2024 and raised concerns that observations and MEOWS did not appear to have been adequately completed. However, we were assured that observations had often been done but had not correctly transcribed from patient records to the PMRT.

During the on-site assessment most women and families felt the environment was suitable. However, 1 woman on the antenatal bay felt that it was crowded, and another felt the environment could be noisy due to other women taking telephone calls.

Staff felt due to the number of beds on the antenatal bay, the environment was cramped. Staff on the labour ward told us they were often short of equipment. Staff told us there was no spare resuscitaires. Staff told us they transferred babies to the Neonatal Unit in resuscitaires, and that equipment checklists often got lost. Staff on the postnatal ward told us they often lost the baby tags to prevent abduction. Staff in triage told us due to the small size of the unit, it was difficult to have confidential conversations. Leaders were aware of the limitations presented by the old estate of the maternity unit and were hopeful many of the issues regarding the environment would resolve when moving to the new hospital. Leaders told us they were aware of how crowded the antenatal bay was, but they needed to ensure quality impact assessments were done before removing beds to ensure safety. Leaders told us they had ordered more baby tags, and how they had liaised with the manufacturer to ensure the tags were correctly alarming. They also told us they are working on making it mandatory that tag numbers were recorded on patient records on the electronic system. Following the on-site assessment leaders fed back that a resuscitaire was immediately moved to triage from an unused area. A room on labour ward was also identified for use by triage staff when undertaking sensitive conversations. Leaders told us they were exploring methods of improving oversight of the sub-waiting room outside triage, such as CCTV and that a checklist had been implemented for emergency equipment in the enhanced care area.

We found out of date stock on the antenatal ward, several items having expired in 2022. We found damaged packaging on one item which meant that it was no longer sterile. We raised our concerns regarding stock to staff on the day. When we revisited on a later date, we found the expired stock had all been replaced. However, the neonatal crash trolley had not been checked on 5 dates. We visited the Serenity suite which was closed and had been for several days previous. We found there was no adult resuscitation trolley and that the nearest one was on ward M1. Staff told us there was a startup procedure and that a maternity support worker would ensure equipment was ready for use. On 28/06/2024 we found there was no resuscitaire in triage which did not conform to national guidelines as women had previously birthed in triage. We also found that the sub-waiting room in triage was not in sight of the main triage unit and there were no emergency call bells or CCTV. We also saw a checklist was missing from a resuscitaire in 1 room on the labour ward. Staff told us that checklists got lost in transit when transferring babies on resuscitaires. Out of date Tempa-Dots were found in this resuscitaire. A Resuscitaire in room 6 had not been checked since 21/06/2024.

The trust did not have effective systems in place to ensure the design, maintenance and use of facilities, premises and equipment adhere to current safety standards. This was exposing women and birthing people and their babies to the risk of harm; this was demonstrated from the observations of the environment and equipment we made during the on-site assessment. There was a process in place to complete daily checks of the neonatal crash trolley; however, this was not effective as it was not being completed consistently. There was no process in place for the checking of emergency equipment in the enhanced care room. Since this was raised a checklist was produced, however this did not include drugs and fluids in this area. Following the S.29A Warning Notice the service provided evidence of a checklist including drugs and fluids. The service compiled a 15-step challenge report which included an assessment of the environment. The most recent area level dashboard in March 2024 showed that the question is the environment well maintained including walls, floors and ceiling? received an average score of 66.7% which did not meet the trusts required standard. The service tested regularly for legionella. We also observed taps on the labour ward carrying out automatic flushes.

Several women recognised that the wards were understaffed and commented that having more staff was an area for improvement. Feedback from CQC’s Maternity Survey 2023 showed women and birthing people rated attention during labour, that is a member of staff being there to help when needed, was rated worse than expected. Being left alone by staff at a time when it worried them was rated somewhat worse than expected.

Staff felt staffing was a significant problem. Many midwives with a specialist role said they were frequently pulled from these roles to backfill staffing shortages, mainly on the labour ward. A doctor told us shortages existed throughout the staff body. A student told us that they had been sent home from a clinical placement in the past as there were not enough qualified staff to support them. Staff gave an example of being pulled from training to work clinically and of having to cancel training. One staff member told us they were given time during their induction period to complete any training, another told us they had to complete mandatory training in their own time. Staff told us how the pay rate for bank shifts had been enhanced to encourage staff to take on extra shifts. However, some staff reflected that low morale sometimes made filling bank shifts challenging. Staff told us how skill mix of staff was not always in line with national guidance. Themes from the recruitment and retention midwife who carried out stay conversations and exit interviews included staffing levels, workload, staff morale, and feeling unable to give the care they would like to. There was a mobile app to enable staff to feedback things that had led them to having either a good or bad day, and also ‘quick wins’. A recruitment drive had taken place across the Local Maternity and Neonatal System, and a number of job offers had been made to student midwives. A staff member spoke of occasions where women had birthed in triage, and how they felt this could be due to a shortage of beds on labour ward, or simply because there was not a midwife free to escort the woman or birthing person to labour ward in time.

On the morning of our first on-site assessment, staffing consisted of a labour ward co-ordinator, another Band 7 midwife who was shadowing and was supernumerary, plus 6 midwives and 2 staff nurses on labour ward. There were 2 midwives on antenatal ward, and 2 midwives working on the postnatal ward. We were told that there were 17 midwives, 1 staff nurse and 3 maternity support workers on shift across the unit that evening. These figures were below the 21 midwives recommended for safe staffing by birthrate plus. During our observation of the midwifery handover on the morning of 6 June 2024 staffing on the labour ward had increased from the day before, consisting of 9 midwives and 3 staff nurses. On the 28 June 2024 we observed staffing requirements for triage were not met. There was a Band 7 and band 5 midwife on duty in triage, this was not in line with RCOG Good Practice Paper no.17 which says triage midwives should be band 6 or above. We noted that managers used a spreadsheet to monitor vacancy rate across the service. This showed a significant current vacancy rate of 18.28 WTE on the delivery suite, and the overall vacancy rate across inpatient services was 29.78 WTE staff.

Staffing was not always in line with birthrate plus. We reviewed the last 4 weeks staffing rotas and found the service regularly did not meet the required levels. A recruitment and retention midwife carried out stay conversations, exit interviews and spoke with student midwives to explore what could be improved to retain staff. Post inspection the service fed back that there were too many shifts showing as unfilled on their system and were working to rectify this. Furthermore, we found a large number of scheduled data entries onto the birthrate plus system had been missed. A number of ‘red flags’ were recorded in the 6 months prior to the inspection in relation to staffing. We looked at medical staffing and found there was no named doctor for triage, doctors were shared with the labour ward which was not in line with national recommendations. Medical staff in maternity and perinatal medicine were below the trust’s target compliance rate of 90% in all modules except fire safety training. Resuscitation of the newborn compliance was 66.7% and infection prevention control level 2 compliance was 62.3%. Compliance rates were generally greater for registered midwifery and nursing staff. All clinical staff were required to attend an annual mandatory Practical Obstetric Multi-Professional Training (PROMPT) study day. At the time of the assessment, the obstetric trainee and maternity support worker staff groups met the trust’s 90% target compliance for this. Midwives and medical staff were required to undertake training on foetal monitoring. Obstetric trainees met target compliance and midwives were just below the trust target. Obstetric consultants were significantly below target compliance in this module at 66%. Midwives were required to attend a mandatory training day which included modules on saving babies lives, diabetes in pregnancy, mental health and bereavement care.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.