Gloucestershire Royal Hospital

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• 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 reviewed learning culture; safe and effective staffing; and medicines optimisation for the safe key question. We found areas of concern in staffing with sharing of learning from incidents. There was no effective governance process for sharing learning with staff. The impact was that risks for women and their babies were not always identified and acted on in a timely way. Agency midwives were not all able to access patient records, IT systems or move freely between areas within the unit while they waited for induction processes to be completed. However, staffing numbers had improved and newly recruited staff were positive about support they received. Recruitment processes made sure appropriately qualified staff were employed in the unit. Staff were trained for their roles and provided with opportunities to develop. Medicines were now managed safely and learning from medicines incidents were shared within the unit. Staff were trained and demonstrated they were knowledgeable about medicines they administered. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Learning from investigations and concerns raised was not always effective and therefore did not embed changes that would improve care for women and people who use maternity services. Staff received feedback from incidents reported. However, not all staff were aware of learning from incident investigations. Not all staff felt there was a proactive safety culture. Some staff felt they had not been supported after raising concerns and were reluctant to do so again. However, most staff knew how to report incidents, received feedback and felt confident to raise concerns with their line manager.

Processes were not effective enough to consistently identify and embed good practices. There was no assurance that learning and improvement opportunities were consistently identified. Not all staff who investigated incidents were trained in how to conduct an investigation. Investigation reports we reviewed had missed a number of points where improvements could be made. When learning was identified, there was often a delay in sharing this with staff. However, some lessons learned from safety incidents had resulted in changes. We were given an example of translation services to support people whose first language was not English. Although this was an improvement on previous processes, managers acknowledged translation services needed further improvement and the current process was not effective enough. Incidents staff reported were reviewed within 24 hours and prioritised for further investigation according to seriousness and severity. There had been improvement in reducing a backlog of incident investigations being completed. Senior managers told us some of these were kept open until actions had been embedded. The process for supporting staff who had raised concerns had not been effective in some cases and staff felt reluctant to raise any further concerns. However, there were actions to improve the culture for raising concerns. Senior staff and non-executive directors were appointed to safety champion roles and represented safety of maternity services to the executive leadership team. The safety champions had developed a programme of visits to speak with staff on maternity units and community see first-hand where safety issues arose.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

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

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

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

People’s experience of using the service was not always positive and some felt they were at risk of harm. A theme from complaints received by the trust related to staff knowledge and experience. Some agency staff had not been familiar with newly implemented patient record keeping systems. Some patients also experienced delays with their discharge because they were waiting for a medical review. However, responses to Friends and Family surveys showed over 85% of people who used the service had a positive experience.

Staffing numbers had improved although there were still concerns about staffing levels, skill mix and support provided for staff. Gaps in rotas were filled using regular bank or agency staff. However, not all agency staff received an induction to the area within which they were working. They relied upon permanent staff for access to electronic systems, such as patient records. Access through securely managed doors was not always readily available for agency staff and they relied upon other staff with an access card to open the doors. This created a risk of delay to patient care. Not all agency staff had their competencies checked prior to working on the unit. Not all staff felt valued by senior management. Staff told us processes to manage poor performance often took a long time to complete and left them feeling hesitant to raise further concerns. Staff did not always get their breaks when they should during a shift. Non-registered staff felt they were not always recognised for their contributions in the same way registered midwives were. However, staff were positive about support provided by practice development midwives particularly for internationally recruited and newly qualified midwives. Staff were also positive about the newly introduced role of ‘flow midwife’ who reviewed staffing and activity levels across the unit. Staff told us medical staff responded when called by maternity staff and provided support. However, trust records showed occasions when consultants had been unable to attend complex clinical situations to support midwifery and obstetric staff. This was not in line with Royal College of Obstetricians and Gynaecologists guidance.

We saw recruitment processes were followed in a way that safeguards people who use the service from harm or abuse. Staff records held the required information prior to starting work at the unit. Records showed there were still vacancies although staffing numbers had increased since our last inspection. Consultant numbers had been increased by 3 since the last inspection. Not all were in post when we visited the unit but recruitment processes were underway.

There were concerns about the processes used to ensure all staff had knowledge of and access to trust policies and protocols. This was because the induction process for agency staff was being reviewed and was not in use at the time of our visit. Some agency staff who were new to the unit did not always have a standardised induction. Consequently, not all agency staff had their own access to trust policies, IT systems, test results and some did not have access through secure doors between maternity areas. However, agency staff who were booked in a block, had received an induction which allowed them access to records, policies and between areas of the unit. A matron had recently been appointed as the lead in supporting agency staff. Recruitment processes made sure staff employed as part of established numbers in the unit were suitable, experienced, competent and able to carry out their role. Processes for training to embed changes in practice and learning from incidents were limited. There was no regular and frequent process to provide ‘skills and drills’ training or scenario based training in the maternity unit areas. ‘Skills and drills’ help to embed safety actions staff take in urgent situations. However, managers monitored staff completion of mandatory training, and maternity staff attended a 2 day, annual Practical Obstetric Multi-Disciplinary Training (PROMPT). Staff were provided with opportunities to develop their roles and advance their career.

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.

Staff were suitably trained to administer medicines with refresher learning being completed annually via an e-learning module. On midwife led units, care staff were able to describe when and how they would escalate any medicines concerns to an appropriate prescriber. Staff on the wards also had access to pharmacy support. Staff were able to provide guidance to people using maternity services about effects of their medicines on them and their baby, helping them to understand risks and benefits of the recommended treatment.

Staff administered medicines safely to people on the maternity wards. They had access to protocols which supported them to follow trust and national guidance when providing care to people. This included information on managing post-partum haemorrhaging or the use of essential oils during childbirth. However, staff were not routinely monitoring the ambient room temperature of clinic rooms where medicines were stored. Failure to monitor and store medicines at the correct temperature can lead to them not working as expected when used.

The trust used a paper-based system to prescribe and record administration of medicines. There were policies and procedures in place to support the safe and effective use of medicines including the management of post-partum haemorrhaging. Midwives used patient group directive as a legal framework to allow them to supply and administer specific medicines. There were processes in place to ensure that a prescriber was involved if a medicine was needed repeatedly. Staff completed routine ‘peer reviews’ as an additional support. This was a process where staff reviewed each other’s practice and provided feedback to keep people safe during pregnancy and childbirth whilst on the units. These discussions provided additional oversight for each midwife whilst caring for people. Learning from medicines errors or near misses within the maternity service was shared but staff were not always aware of similar learning from across the trust.