Basildon University 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

There was a culture of safety and learning. Risks were dealt with willingly as an opportunity to put things right, learn and improve. Staff felt confident to raise concerns, however, they did not always feel encouraged and supported to do so. Incidents were appropriately investigated, however, there were sometimes delays with embedding learning due to the time taken to complete investigations. Safety and continuity of care was a priority throughout people’s care journey. There were systems in place to ensure a collaborative, joined-up approach to safety that involved patients, along with staff and other care partners. There were effective systems and processes in place, and a strong awareness of the risks to people across their care journeys. People using the service were informed about any risks and how to keep themselves safe. Risks were assessed, and people and staff understood them. Risk assessments about care were person-centred, proportionate, and regularly reviewed. People were cared for in safe environments that were designed to meet their needs. However, some staff felt there was not enough equipment to meet the needs of patients, and equipment was not always maintained in line with policy. Recruitment practices were safe. However, compliance with training did not always meet the recommended target. Staffing levels did not always meet planned levels. However, twice daily staffing reviews and the use of the Birth-rate Plus Acuity Tool ensured staffing concerns were escalated and mitigations put in place to reduce risk. Staff received training that was relevant to their roles and responsibilities, and support they needed to deliver safe care. The approach to medicines generally reflected current and relevant best practice and professional guidance. Medicines were generally appropriately prescribed, supplied, and administered in line with relevant legislation and current national guidance.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Women and birthing people we spoke with during our assessment told us risks were explained by staff and they felt involved in decision making, although there was sometimes differing views and advice on treatment. They told us they knew who to contact during their care journey. Patient comments included “I was kept informed of who I could speak to and have all my follow up letters printed”, “I feel safe and well cared for”, and “I have all contact details in my notes should I need them”. Patient survey data showed that 83% of birthing people felt they were involved in decisions about their care, and 81% felt their concerns were taken seriously. As part of the assessment, we reviewed 36 complaints that had been received between March 2023 and February 2024. The service had recognised themes from complaints, including, but not limited to, lack of clinical decision making; staff attitude; poor care; and lack of information/communication.

A system was in place to investigate incidents and identify learning. Incidents were reviewed daily and involved a collaborative approach, between the risk and governance team and management team, to review incident content and grading. Incidents requiring immediate attention were investigated as a priority, to ensure potential safety concerns were addressed and mitigated. Monthly governance meetings were held to discuss incidents, identify themes and learning, and action to reduce future occurrence. The maternity assurance committee met monthly to review and monitor incident investigations. The committee received assurance that governance arrangements were in place to monitor the completion of action plans and the subsequent effectiveness of risk reduction measures. Staff we spoke with during the assessment felt confident to report incidents in line with trust policy. However, they did not always feel encouraged and supported to report incidents and raise concerns, such as staffing and induction of labour delays. Staff were able to discuss how incidents were reported and the how these were reviewed and fed back to staff. Staff told us they were able to raise concerns through a variety of avenues, including freedom to speak up guardian (FTSUG) and knew how to contact them. However, staff were not confident that their concerns were always listened to, for example a staff member had emailed a senior leader twice and did not receive a response or acknowledgement. Staff were able to give examples of a variety of methods used by leaders to share feedback from incidents and identified shared learning such as safety alerts, team meetings, emails and posters. Leaders were aware of the need to engage all staff to ensure there was a proactive culture of safety and were exploring additional methods to share this, such as the introduction of podcasts for staff.

Compliance audits to monitor the effectiveness of the service were not always completed by managers and leaders. For example, time taken to triage dependent on the identified RAG rating were not completed regularly. We requested audit data for the last 3 months. A retrospective audit was undertaken and provided which showed that triage was within 15 minutes for the 3 months and in line with national guidelines. Audits of MEOWS had not been completed for the 6 months prior to our inspection despite two serious incidents at another maternity unit in the trust identifying these were required to support escalation of deteriorating women. Specialist midwives were not always able to inform us of their current ongoing audits and service evaluations. Incidents were appropriately investigated, however, there were sometimes delays with embedding learning due to the time taken to complete investigations. We requested to review the last 3 completed maternity investigations relating to a safety incident. We found that there was a full complement of multi-disciplinary team in line with policy, however, duty of candour was delayed in 1 case and identified learning was not always embedded resulting in similar incidental finding reported following the completed investigations. Actions to address the delays had been put in place, including additional work to manage the investigations with oversight from the Director of Midwifery, and weekly reports shared with the site and wider senior leadership team for oversight of progress with delays. A process and policy was in place for staff to raise concerns (whistleblowing policy). The policy ensured members of staff were aware of their duty of candour, openness, and transparency, and to put in place a mechanism for them to raise concerns at work. Additionally, a duty of candour policy was in place to provide staff clarity on their obligation with regards to being open and the duty of candour.

Service users we spoke with told us they were informed of their planned care and treatment. They knew who to contact if they required support. Follow up arrangements were made prior to discharge, which women preferred. One woman in triage stated she felt heard and was happy to speak up in care planning and felt her opinion was welcomed. Women on labour ward had been shown how to administer medication on discharge and were informed that community midwives were being organised for a home visit. This was consistent with the results of the CQC maternity survey where antenatal care and contact information and mental health screening scored in line with the national average. Women, however, responding to the CQC maternity survey did not always feel they were involved in decisions regarding induction, communication did not aid decision making and pain management during labour fell below the national average.

Safety and continuity of care was a priority, and there was a strong awareness of risks to people. There were processes in place to identify risk for women and babies. Risk assessments were completed by staff, including but not limited to, domestic abuse, mental health, foetal movements, and smoking. We reviewed 4 care records for post-natal women and found good evidence of completion of risk assessments which were regularly updated. Staff received training in how to identify deteriorating patient through the use of tools such as the national early warning score (NEWS), paediatric early warning scoring (PEWS) and Modified Early Obstetric Warning Score (MEOWS), and were able to discuss the processes in place for escalation. The use of NEWS/MEOWS/PEWS was to support the detection and response to clinical deterioration. High risk patients were identified in triage using the nationally registered Birmingham Symptom Specific Obstetric Triage System (BSOTS) triage tool within 15 minutes of arrival. On arrival women were RAG rated to ensure that high risk women were reviewed within 30 minutes by a midwife and within 1 hour by medical staff. Staff knew how to make a safeguarding referral and who to inform if they had concerns. The service had a safeguarding team who staff could access when they had concerns. However, staff also told us the safeguarding midwife was not always available and sometimes referrals were completed but added to the system at a later date. Shift changes, handovers and safety huddles included all necessary information to keep women and birthing people and babies safe. During the inspection we attended staff handovers and found that staff used situations, background, assessment and recommendation (SBAR) to provide both verbal and an up-to-date handover sheet with all the key information needed to keep people safe. Multi-disciplinary (MDT) handovers and safety huddles were actively monitored for effectiveness and compliance.

Care and support was planned and organised with people, together with partners and communities in ways to ensure continuity. The views of people who used services and partners were listened to and taken into account. Staff working for partner organisations, such as the local maternity and neonatal voices partnership (MNVP), told us they worked closely with the service to help make sure women’s and birthing people’s views were represented and maternity services were designed to meet local needs. They worked together to determine how accessible information was and what was needed to improve care and choice for all women and birthing people. MNVP held quarterly meetings with the service to escalate feedback from women and birthing people to maternity leads. A big focus had been on supporting the diverse communities who used the service. The MNVP worked with ethnic community leads to shape improvements for maternity services across Mid and South Essex. They told us they had a good working relationship with the Heads of Midwifery and Director of Midwifery and felt this collaboration was having a positive impact on women and birthing peoples pregnancy experience.

Staff used a nationally recognised early warning tools to identify women, birthing people and babies at risk of deterioration. We reviewed care records for 4 women and babies. There was evidence of evaluation of risk at each contact through their care journey, with clear documentation of risk that was acted upon. Audits to monitor use of the nationally recognised tools for deteriorating patients such as MEOWS and NEWTT was reviewed. January to March 2024 showed a lack of compliance across all parameters, with areas such as identification of deterioration, escalation of care and monitoring frequency. Data showed compliance varied between day and night shifts. We were not assured proactive steps were taken to improve compliance. Processes to identify safeguarding, mental health and domestic abuse were embedded with evidence that staff had followed processes. For example, we saw a recognition and risk assessment for a patient who had female genital mutilation by community midwife and follow up with consultant. Audits to monitor compliance and performance of systems and process were not always completed. We requested the surgical safety checklist audit for the last 3 months. This was not available as they were not completed, therefore we were not assured if processes were being followed to reduce the risk of potential errors. Lack of regular auditing meant that leaders were not always aware of shortfalls, a lack of senior oversight and accountability. Audits for compliance of completed risk assessments for pressure ulcers and risk of VTE on admission and post-delivery were reviewed for October 2023 to March 2024. Overall compliance fluctuated, however, had shown a consistent improvement 3 months prior to the assessment. All patients were triaged within 15 minutes of arrival, however, clinical review in line with the recognised risk rating varied with delays in doctor reviews across all 3 months data from January to March 2024.

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

People were informed about any risks and how to keep themselves safe. We spoke to 4 women during our assessment, they told us they were involved in decisions, risks were explained and their opinions were listened to. Within triage, a woman we spoke with told us that her baby was measuring large and was having scans and appointments with her consultant to monitor this. She was happy with their communication as well as the community midwife. She felt heard and happy to speak up. A woman on the post-natal ward told us that due to the complex medical condition, several specialities were working collaboratively to ensure risk was discussed and a care plan was in place to support her wishes and always felt informed.

Risks were assessed, and people and staff understood them. Staff told us they had training for their roles to identify a worsening situation for mother or baby. They were able to describe how they would escalate this in line with trust policy. Staff were able to explain risks to women and birthing people and were able to advocate so that women and birthing people received appropriate explanations to make decisions. For example, during the assessment we heard a woman was not happy with the treatment plan that advised to proceed to a caesarean section. The midwife reported to the midwife in charge that the medical team explained the risks of both having the surgery and the risks to both of them should they not consent. They were allowed time to decide based on the information presented to them. Staff told us they would escalate clinical concerns, reviews and mothers waiting for labour ward to the co-ordinator or duty manager via mobile or bleep system. They stated that the co-ordinator and duty manager were very responsive. Most staff were able to tell us at least one of the top 3 risks for the maternity service, and senior staff were able to explain the 3 risks.

Risk assessments were completed by staff at point of contact and throughout their care journey. They were person-centred, proportionate, and regularly reviewed with the person, where possible. There were systems in place to ensure staff completed necessary training to identify risk. This included, but was not limited to, fetal monitoring training. Fetal monitoring training was fully embedded and met the trust target with compliance at 98%. Staff who were not compliant with fetal monitoring training due to failing the competency test (85%) were not allowed to provide intrapartum care. One-to-one support was provided by the fetal surveillance specialist midwives for staff requiring support to pass the competency test. Service managers and leaders audited the compliance of record keeping in line with trust policy. We requested audit data for the last 6 months which showed that audits of patient notes reviewed 4 key areas (patient identification, date and time of each entry, timeliness of last 5 entries in 24 hours and authentication of entries and method of authentication). We found that date and time compliance was at 50% in October but had improved to 100% in February and March 2024.

Women and babies were cared for in environments that were designed to meet their needs. Women and birthing people we spoke to during our assessment told us they felt safe, well supported and cared for by both the nursing and medical teams.

During the assessment, some staff felt there was not enough suitable equipment to meet the needs of patients and their families. For example, staff told us that in some areas there were not enough fetal monitoring equipment. Staff were unable to tell us who was responsible for the servicing of equipment in areas or that ligature risk assessment had been completed.

The design of the environment followed national guidance. The maternity unit was fully secure with a monitored and locked entry and exit system to the different units and reception areas. There were ward clerks at reception desks during normal working hours. The service had 2 dedicated maternity theatres for elective and emergency caesarean sections and other maternity related surgery adjacent to the delivery suite. The service’s bereavement suite was developed to provide parents with a private entrance to a secure space to have and spend time with their baby. The suite was sound proofed, beds and seating areas were large enough for both parents to be comfortable, there were shower facilities and a small kitchen area. Maternity triage consisted of a dedicated waiting area, one 2 bedded bay and a single room with a built-in scanner that enabled staff to relay information in a private setting. Although the maternity unit was all located in one building, the triage unit was not situated next to delivery suite but on another floor, which potentially may delay transfer of women to delivery suite. There was a 4-bed high dependency bay for women or birthing people on delivery suite. Babies who needed a higher level of monitoring after delivery were cared for in transitional care cots/beds on the postnatal ward. Staff usually completed safety checks of specialist and emergency equipment and we saw adult and newborn resuscitation equipment was mostly checked daily, with less than one missed entry a month on average. Call bells were accessible to women and birthing people if they needed support and staff responded quickly when called. Staff disposed of clinical waste safely. Sharps bins were labelled correctly and not over-filled. Staff separated clinical waste and used the correct bins.

A log was kept ensuring equipment was tested on a regular basis. However, data received from the service following the assessment showed some pieces of equipment were overdue a review. This was consistent with our findings. During our onsite assessment, we checked 10 pieces of equipment for service dates and found 4 were past their re-test date. This was a concern at our last inspection. We reviewed emergency trolleys and equipment for compliance with daily/weekly checks in line with trust policy. We found some gaps in the daily check list records. However, weekly compliance audits were in place to ensure resuscitation trolleys were stocked well and equipment in date. Compliance between January – March 2024 was generally between 95 and 100%. Areas we visited were visibly clean. I am clean stickers were used throughout the department to demonstrate routine cleaning. Monthly IPC audits were undertaken, which included, but not limited to compliance with hand hygiene, decontamination, and waste management. We reviewed audit data from January 2024 – March 2024 for the delivery suite, MLBU, and ward area, which showed compliance range between 82% and100%. We saw improvements were made following areas of poor compliance identified through the auditing processes. Where the service had identified areas of poorer compliance with checks, they had also identified actions required to improve. For example, an action plan was in place for birthing pool temperatures due to compliance ranging from 52-84%. An Entonox Antenatal Training Pathway Policy was developed in response to a recent Entonox high exposure incident. Entonox is used for the relief of acute pain and discomfort. An ongoing programme of quarterly monitoring to measure exposure levels of Entonox in the maternity unit was in place.

Women and birthing people told us they felt safe and supported and knew who to contact if needed. They were happy with staff, their skills and the information given to them, including managing complex cases. One woman said they felt well supported with a team that understood their medical needs.

Staffing levels did not always meet planned levels. Staff told us there were not enough permanent staff. Shifts were often covered by bank or agency staff. While staff said this did not always result in issues, they did say sometimes things were missed, such as booking elective caesarean sections. Some staff also reported not being able to take scheduled breaks due to low staffing levels. Senior staff told us there were challenges with the recruitment of midwives locally but they had an international recruitment programme for both midwifery and medical staff. Workforce and vacancies of posts were reviewed monthly. Planning for vacant posts were discussed at governance meetings to avoid gaps in service where possible. The service had an ongoing rolling recruitment programme to address any potential vacancies as early as possible to cover prospective maternity leave, retirement and staff leaving. The vacancy rate for maternity services as of January 2024 was 8.6%, against a trust target of 11.5%. The sickness rate for the same period was 4.99%, against a trust target of 3.5%. Staff told us they received training that was relevant to their roles and responsibilities. As well as mandatory training, staff received maternity specific training as well as learning identified through incidents. They knew when to complete required training and received reminders from their managers. We were told that compliance with training was monitored through a ‘live’ database. International midwives had opportunities to develop through the preceptorship course and supported by practice development nurses. However, they did not always feel included in learning following serious incidents and this was being addressed by the professional development team. Managers requested bank staff familiar with the service and made sure all bank and agency staff had a full induction and understood the service.

During our visit, midwifery staffing numbers were lower than planned. Managers looked at the acuity in each area and moved staff to where they were most needed to ensure staffing was safe. The midwife-led unit was closed on the first day of our inspection visit due to the lack of staff, although it was open on the second day. We observed a safety huddle where planned staffing was discussed. This process allowed for identification of areas of low staffing and time to fill vacant shifts. Leaders told us staffing was a nationally recognised concern and that twice daily staffing reviews and the use of the Birth-rate Plus Acuity Tool ensured staffing concerns were escalated appropriately and mitigations put in place to reduce risk. The most recent assessment (October 2023) of the recommended safe staffing ratios for the maternity service compared favourably to whole time equivalent (WTE) in line with national recommendation. The overall ratio was 20.5 births to 1 WTE midwife, which was better than the national ratio. An ‘Escalation for Safe Care Provision and Safe Staffing for Maternity Services’ policy was in place, however, this had passed its review date. To support a joint approach, the service used a regional escalation policy (Opel scoring system), which was communicated via a twice daily joint sites meeting. Data for March 2024 showed all women received 1:1 care in labour; the midwife to birth ratio was 1:24; there were no occasions when the delivery suite coordinator was not supernumerary; community midwives were called in on 3 occasions as part of the escalation policy; there were no external diversions. Short staffing was filled with the use of bank or agency staff, however, in September 2023 and October 2023 data showed there were staffing deficits of 30 midwives each month on planned numbers. Between January 2024 and March 2024 169 out of 182 shifts were understaffed, with 33 of these shifts being under the planned staffing number by more than 5 staff.

Compliance with training did not always meet the recommended target. The National Safeguarding Intercollegiate Guidelines state all registered healthcare staff who assess, plan, intervene or evaluate the needs of adults including midwives should complete training to level 3 for both children and vulnerable adults. Training records showed not all staff had completed both level 3 safeguarding adults and level 3 safeguarding children training at the required level for their role. Compliance for level 3 safeguarding adults was particularly low at 37% and level 3 safeguarding children was at 76%. This was a concern at our last inspection. Not all maternity staff kept up to date with their mandatory training. Data requested showed overall 79% of staff had completed the required training against a trust target of 85%. Managers supported staff to develop through yearly, constructive appraisals of their work. Compliance with annual appraisals was at 86% across all maternity inpatient staff groups, which was an improvement since our last inspection. A clinical practice educator lead supported midwives. Safety was promoted through recruitment procedures and employment checks. Staff had Disclosure and Barring Service (DBS) checks completed before they could work. DBS checks help employers make safer recruitment decisions and prevent unsuitable people from working with vulnerable groups. The service had an up-to-date recruitment and selection policy to ensure they were able to recruit the right people with the right skills and attitudes to deliver their strategic objectives. Leaders told us their recruitment and selection processes were designed to be fair and non-discriminatory, with equality of opportunity an integral part of their recruitment and selection processes.

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.

People were appropriately involved in decisions about their medicines, and the level of support they needed to manage their medicines safely. Women and birthing people told us they were given enough pain relief and staff taught them about their medicines before they were discharged.

Staff we spoke with were able to tell us about the safe storage, prescription, access, and administration of medicines. Staff on the birthing unit told us there was a new system in place where expired medicines were stored in a clear container for safe disposal by the pharmacy team. Staff told us that allergies for medicines were documented on the electronic system and was not always documented within the paper prescription charts. Staff would document which medications they needed to administer for patients on their handover sheet as there were no structured drug rounds in place.

The approach to medicines generally reflected current and relevant best practice guidance. Staff mostly completed medicine records accurately and kept them up to date. The service used a paper prescribing system. Midwives could access the full list of midwives’ exemptions, so they were clear about administering within their remit. We looked at 11 prescription charts and found 2 instances where medicines had not been administered, however staff had not recorded a reason for this. The controlled drug (CD) register was mostly compliant. Staff checked controlled drug stocks daily. However, staff did not always maintain accurate records of controlled drugs that were not given in full, in line with trust policy. We found 1 instance where the administered amount of a controlled drug was not accurately documented within the CD records. The pharmacy team supported the service and reviewed medicines prescribed. These checks were recorded in the prescription charts we checked. Staff stored and managed all medicines and prescribing documents safely. The clinical room where the medicines were stored was locked and could only be accessed by authorised staff. Medicines were in date and stored at the correct temperature. Staff monitored and recorded fridge temperatures and knew to take action if there was variation. This was an improvement since the last inspection where we found that processes were not in place for the safe storage of medicines.

Staff followed national practice to check women and birthing people had the correct medicines when they were admitted, or they moved between services. Medicines were prescribed in line with guidance, for example, anti-coagulant dosage was based on current weight and prescribed correctly. The service did not provide medicine management training for staff, although they had introduced medicines safety champions on ward areas, which had helped to improve medicine safety.