Salisbury District 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

We assessed 6 quality statements. There was a positive learning safety culture where events were investigated, and learning was embedded to promote good practice. Staff were open and honest when things went wrong or could be a risk. Staff provided safe care and treatment. The environment was now safe, well maintained and met people’s needs. There had been a clear focus on staff retention and the service had seen a significant improvement in staff retention. However, not all staff met the 90% training compliance for mandatory and PROMPT training.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We spoke to women during our inspection who shared their maternity experiences and reviewed the Friends and Family Test (FFT) results provided by the service. Women said they felt safe, and their maternity care and treatment was explained to them throughout the maternity journey. Women told us they were mostly seen and reviewed quickly by midwives, and they were kept updated and informed in regard to their care. Women felt encouraged and supported to raise concerns without fear of being treated negatively if they do so. Women told us ‘I feel safe here’. However, FFT results highlighted some women had experienced delays and long wait times when waiting for an obstetric review, medical consultation or scan result.

Staff told us they felt confident to report incidents and were supported to proactively identify and manage risks before safety events occurred. Incidents were reviewed on a regular basis so service leads could identify potential risk and act quickly. Staff told us incidents and complaints were appropriately investigated and reported. Lessons learnt were shared within handovers, information boards and staff newsletters to improve staffing understanding and learning. For example, following an increase in incidents for 3rd and 4th degree tears the education team and pelvic floor specialist midwife had developed an action plan to improve awareness and care. Review of the maternity dashboard showed there had been an improvement in 3rd and 4th degree tears for August and September 2024 with incidence of below the national average of 5%. Staff understood the duty of candour. They were open and transparent and gave women and their families a full explanation when things went wrong. There was a process in place to review incidents and to complete Duty of Candour on a weekly basis through the Patient Safety Summit which was chaired by the Chief Nursing Officer or Chief Medical Officer.

Incidents were reviewed via a multi-disciplinary panel within a 72-hour period following an incident, and if required was reviewed at the trust weekly Patient Safety Summit. Clinical deterioration was audited monthly and discussed within the monthly audit meeting which was attended by clinical staff with different levels of experience. There was ongoing funding and work to improve translation services for women. The service was currently working with the Patient Advice and Liaison Service to develop further information and maternity leaflets around procedure. For example, inductions of labour.

Women were clear on how to contact the service if they had concerns during their pregnancy. Women were assessed using a situation, background, assessment, recommendation (SBAR) tool by an experienced midwife and directed to the appropriate care. Women attended the day assessment unit for both scheduled and unscheduled care and the service completed monthly audits to determine how long women waited for further assessment and if required, a medical review.

Staff described a positive safety culture and felt confident that leaders had taken action to address compliance levels within day assessment unit, with employing a lead midwife and introducing core staff. The service had a standard operating procedure (SOP) for maternity clinical escalation. The SOP identified the key steps to support clinical escalation and there was a clinical escalation flowchart in place. Staff told us they felt confident they could escalate concerns to the leadership team, and they would be listened to. Leaders had recognised there was a gap in service between scheduled and unscheduled care and there was a period of time where there would be one midwife. Senior leads felt this was unsafe and a twilight midwife role was put in place to bridge any gap in service between 4pm to midnight. This meant there was always two designated band 6 midwives within the unit. Staff we spoke to were confident the service prioritised women and women were being seen within the required timeframe by midwives.

The board safety champions visited the maternity unit. The team liaised with outside representatives such as the maternity neonatal voices partnership (MNVP) group to review services, monitor risk and provide the board with a report of maternity services. The Maternity and Neonatal Governance and Risk Framework was co-written by the maternity service and the maternity improvement advisor from NHS England. The framework provided guidance around risk assessments and audit process to ensure appropriate guidelines are followed and incidents reviewed appropriately.

There were clear processes to mitigate risks within the maternity service and a standardised process to complete regular audits of deterioration and escalation to obtain oversight. From September 2024 there were 36 incidents open. Incident forms were completed if regular audits were found not to be meeting service targets for safety, such as assurance and risk around CTG and fresh eyes completion. An incident report was completed for further escalation and oversight. Perinatal deaths were reported using the perinatal mortality review tool (PMRT) and the service met for PMRT meetings to discuss specific cases. There had not been a meeting for the last three months due to no outstanding cases to review. The service reported there had been no cases of fetal losses between 22 -23+6 weeks and no cases of stillbirths over 24 weeks of gestation within the last 6 months. The service maternity dashboard was currently under review with local maternity and neonatal systems. NHS England maternity improvement advisor was working with senior leaders to produce a dashboard which aligns with the national maternity dashboard. This would allow the service to benchmark against local and national data. The service had no incidence of nosocomial incidents and 1 case of sepsis from March 2024 to August 2024. Pool evacuation training was part of PROMPT training plan and included an evacuation flow chart and training videos. Training data for PROMPT showed not all staff had completed their training. PROMPT training figures for medical staff was low at 68.2%, midwives 85.2% and midwifery care assistants 77.5%. The service followed the ‘Five Steps to Safer Surgery’ World Health Organisation (WHO) checklist which included a sign in, time out and sign out checks.

Women were asked safeguarding questions during each antenatal contact.

Staff understood and could describe how to protect women from abuse. Staff could give examples which demonstrated their safeguarding understanding. Staff had training on how to recognise and report abuse and they knew how to apply it. Staff understood the importance of supporting equality and diversity and ensuring care and treatment was provided in accordance with the Equality Act 2010. Managers stated that Women were asked safeguarding questions during each antenatal contact. Risk assessments were completed in antenatal records and the service had a maternity booking antenatal care policy in place. The trust had defined recruitment pathways and procedures to help ensure that the relevant recruitment checks had been completed for all staff. These included disclosure and barring service (DBS) checks prior to appointment. Senior staff used the Maternity Escalation Policy to ensure oversight and transparency when staffing and incidents occurred. Staff told us they were encouraged to complete incident report forms if they were understaffed or had missed breaks.

Staff received training specific for their role on how to recognise and report abuse. Training records showed both midwifery and obstetric staff did not meet the trust target of 90% of safeguarding training. Overall staff compliance was 83.8%, with 86.8% of maternity staff and 60% of obstetricians in October 2024 having completed level 3 safeguarding Children’s training. All consultants had completed their level 3 Safeguarding children’s training. The services had 8 new rotational obstetricians join the trust between August 2024 and October 2024 which had reduced the training compliance. All staff who were non-compliant had been booked onto safeguarding training following our inspection. A protocol to enable practitioners to work together with families to safeguard unborn babies where vulnerability and risk indicators were identified was in place. The protocol provided an agreed process between Health agencies, Children’s Social Care and other agencies working with the mother and her family on the planning, assessment and actions required to safeguard the unborn baby. Safeguarding supervision was in place for maternity staff with regular supervision given to all staff directly working with women and families with safeguarding concerns. When there were women with a baby and children on a child protection plan or had safeguarding concerns, they were visited daily by the safeguarding midwife and an appropriate plan of care and discharge was completed. The service held a listening event for younger women working with the family nurse partnership. The team contacted pregnant women under the age of 18 years to ask them if they wanted to take part as the service recognised their voices were not always heard.

Women told us they felt well informed to make decisions about their maternity care. The birth centre had a strict low risk criteria for women. However, the service listened to women and the criteria had recently expanded following feedback from women.

Staff and leaders told us there were several risk assessment processes for women during their antenatal, intrapartum and postnatal care for staff to identify women from vulnerable backgrounds. For example, during antenatal booking midwives were responsible for taking a detailed history and referring women to be seen by the obstetrician if risk factors were identified. Women were supported to develop personalised care plans with their midwife or obstetrician which identified wider health needs and a plan of care.

The service had a dedicated telephone line for triaging women. Women were assessed by a trained midwife who used a standardised triage situational, background, assessment and recommendation (SBAR) tool to identify risk. The SBAR tool was used within training days for fetal monitoring and PROMPT and during handover of cases whilst risk assessing women. The standard operating procedure for the use of SBAR handover in maternity was currently under review. It highlighted the responsibility of the midwife completing handover and included using SBAR within the day assessment unit to provide information for all transfers. The service completed an audit of SBAR use between June 2024 to August 2024, with a standard of 85% compliance. Audit showed that SBAR handover from labour ward to Beatrice ward was 89% and a compliance of 61% during handovers at shift changes on labour ward. From June 2024 to August 2024 the service had 552 assessment periods relating to induction of labour and during that time there were noted to be 23 incidents related to the delay of IOL, which is a low number. We reviewed 10 sets of women’s records which identified high and low risk women were identified at booking, risk factors were identified, and risk assessments were completed at every contact. Unwell women who had been readmitted to the postnatal ward were reviewed daily by the medical team and all transitional care babies were reviewed daily by the paediatrician. The service had a twice daily ward round on the delivery suite as per national guidance and there was consultant presence on-site. Neonatal and maternal readmission rates for the service were low. Between March 2024 to August 2024 neonatal readmissions were between 3-11.5% and maternal readmissions was 0.6%.

Women told us during our inspection they felt safe in the maternity environment and were supported to understand and manage risks. The patient experience survey showed, most women were happy about their experiences and care. Staff had a good awareness of the women’s medical history, and they were well supported. Women felt they could raise concerns and ask for support if required. Antenatal and postnatal women admitted onto Beatrice ward were included in the patient experience survey to establish women’s experiences. Information from the survey was mostly positive.

The service introduced antenatal beds onto the postnatal ward in March 2024 to improve women’s antenatal experiences and flow on the labour ward. The inspection team had initially received negative reports in response to this change. However, staff during the inspection were positive and happy with the change.

The maternity unit was located within the older part of Salisbury District hospital. The Day Assessment Unit was small and at times there was limited space for women to be seen for assessment or waiting for scan results. Call bells were accessible to women when they needed support and staff responded quickly when called. The maternity unit was fully secure with a monitored entry and exit system and the service had completed baby abduction drills. The service had suitable facilities to meet the needs of women and families. There were facilities for partners staying on the ward and each postnatal bed had a reclining chair for partners to stay. All equipment and store cupboards during the inspection were visibly clean, tidy, and uncluttered. A fridge specifically for infant milk storage was kept in a locked room which stored medicines and dressings. The name, hospital number, date and time expressed were written clearly on all labels. The milk fridges were checked daily to ensure they were maintained at the correct temperature for safe storage. The milk kitchen was open to allow access to sterilising facilities, although all fridges containing infant milk were locked. The service had a purposed designed bereavement area to help support women and their families. The bereavement suite provided an area of privacy away from the maternity area. The service had enough suitable equipment to help them to safely care for women and babies. During the inspection, we did observe that the examination light in the second theatre was broken and currently awaiting repair. The risk was being mitigated by the use of a mobile light whilst the service waited delivery of a replacement part. We were assured by the senior team that actions were in progress and the risk had been escalated, placed on the risk register and shared at the daily safety huddle and each handover.

Emergency and specialist equipment checks were completed daily by staff. The service completed monthly cleaning and hand hygiene audits. From June 2024 to August 2024 all areas of the maternity service scored between 98-100% compliance for cleaning and hand hygiene audits. Staff regularly checked birthing pool cleanliness, and the trust had a contract for legionella testing of the water supply.

Women felt staff had a good level of awareness of their medical history, regardless of where they were in their pregnancy and postnatal journey.

Staff felt there had been a significant improvement in staffing over the last 3 months. Staff told us they felt leaders had listened in regard to concerns around staffing and there had been an improvement in staffing in all areas of maternity teams. Staff we spoke to, told us that all specialist midwives and managers were supportive and would work clinically when required to support the team. Senior leaders were visible and approachable in the service for women, families and staff. Leaders were well respected by the maternity team. A staff forum was in place for all Maternity and Neonatal staff to strengthen communication and to share information and discuss staff queries or concerns.

During our inspection all areas of the maternity service had adequate staffing and we observed staffing rotas. All areas felt calm and staff we spoke to were positive about staffing levels.

A formal Birth Rate Plus assessment was completed in 2024, which reviewed the acuity of women who used maternity services. The review recommended a birth to midwife ratio of 1:24. The service did not maintain 1:24 but was consistently maintaining 1:25 midwife to birth ratio. Staffing was monitored daily, and staff were redeployed based on the acuity rather than being rostered in a particular maternity area. A new preceptorship and induction programme had been implemented by the education team and the service had introduced internationally trained midwives. There were no core staff dedicated to the birthing unit. Midwives for the birthing unit were designated daily and were dependant on women using the service. The service did not close to admissions unless it was full or there were staffing issues which meant staff were working within the maternity escalation policy. Staff were mostly compliant with their mandatory training. Training compliance for the trust was 90%. Maternity staff were 88% compliant and medical staff 85%. There had been a significant reduction in the midwifery vacancy rate, with the service being on track for full recruitment of maternity staff by October 2024. From March 2024 – August 2024 the supernumerary labour ward co-ordinator was 100% compliant and the service was 100% compliant with women receiving 1:1 care in labour. Data showed the number of red flag incidents were low. The service met the 100% target of compliance for consultant obstetricians to be in attendance for specific clinical situations set out by the Royal college of obstetricians and gynaecologists. For example, women with a postpartum haemorrhage of 2 litres and above and maternal collapse or deterioration. The service had long term and short-term sickness of middle grade and junior doctors. The service had introduced a new rota for doctors to work 1:8 to improve well-being.

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.