The Ipswich Hospital

Updated 16 June 2021

East Suffolk and North Essex NHS Foundation Trust (ESNEFT) provides both acute hospital and community health care and was formed on 1 July 2018 following the acquisition of The Ipswich Hospital NHS Trust by Colchester Hospital University NHS Foundation Trust. ESNEFT maternity consists of services at Ipswich, Colchester and Clacton.

At Ipswich Hospital, the delivery suite consists of six birthing rooms with three fully equipped obstetrics and gynaecology theatres, of which one is a dedicated emergency obstetric theatre to support consultant-led care and a three bedded midwifery-led birthing unit for women identified as low risk of complications. The triage area contains three beds, with two assessment rooms and a quiet room which can be used for bereaved families. The maternity ward has 23 beds and accommodates both antenatal and postnatal women. In addition, specialist midwives for cardiotocography, bereavement, clinical effectiveness, practice development, mental health, birth choices, safeguarding, smoking cessation, antenatal and new-born screening and infant feeding work within the multi-disciplinary teams. Ultrasound is provided at Ipswich and Colchester sites and includes fetal medicine specialist services.

From April 2020 to March 2021 there were 3137 deliveries at Ipswich Hospital.

We last inspected the maternity service at Ipswich Hospital between 11 June and 18 July 2019. The report was published on the 8 January 2020. The maternity service was rated good overall, with safe rated as requires improvement, effective, caring and well led rated as good and responsive rated as outstanding. The trust was issued with two requirement notices in relation to breaches in Regulation 12 of the Health and Social Care Act (RA) Regulations 2014 and was told to improve.

We carried out this unannounced, focused inspection of maternity services because of emerging concerns in relation to the safety and quality of the services.

Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activities. We carried out a focused safety inspection of maternity services related to the concerns raised, this does not include all our key lines of enquiry (KLOEs).

How we carried out the inspection

As part of this inspection we visited the following areas within the maternity services; maternity triage, the consultant-led delivery suite, ante-natal and post-natal ward and maternity theatre. We spoke with 26 members of staff; including service leads, matrons, midwives, doctors, maternity care assistants and administrative staff. We observed care, attended two handover meetings and ward rounds and reviewed 10 sets of maternity records. We reviewed two emergency trolleys and carried out medicine checks on two ward areas. We also looked at a wide range of documents including policies, standard operating procedures, meeting minutes, action plans, prescription charts, risk assessments and audit results. Before our inspection, we reviewed performance information about this service.

Focused inspections can result in an updated rating for any key questions that are inspected if we have identified a breach of regulation and issued a requirement notice. In these cases, the ratings will be limited to requires improvement. Because of this, there were changes to ratings for maternity services. Safe remained the same but well led went down giving an overall rating of requires improvement for maternity services at Ipswich Hospital.

Our rating of services went down. We rated them as requires improvement because:

• Staff did not always feel respected, supported and valued by the leadership teams. Staff were not clear about their roles and responsibilities. Staff we spoke with told us morale was low and there was a disconnect between unit staff and the leadership team.
• Leaders and teams did not always use systems to manage performance effectively. There was insufficient oversight and management of risks. The risk register was not up to date and leaders were unaware that mitigating actions were not being carried out. Some incidents were graded as no harm thereby potentially missing the opportunity to review the incidents in greater detail and improve practice.
• The service did not have enough maternity staff with the right qualifications, skills, training and experience to keep women safe from avoidable harm and to provide the right care and treatment. The number of midwives and maternity care assistants on duty did not match the planned numbers.
• Not all staff had completed mandatory training or specialist training in line with trust requirements. Compliance rates for medical staff were low. Managers could not be assured that medical staff were competent in key aspects of their role due to failure to complete this training.

See the Maternity section for what we found.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Updated 8 January 2020

We rated it as good because:

• The service had enough staff to care for patients and keep them safe. Staff understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However

• Medical and nursing staff did not meet the trust target for mandatory training or for safeguarding adults training.
• Staff did not label monitoring equipment or hoists after cleaning and had not completed appropriate risk assessments for VTE in nine of the 27 (33%) nursing and medical care records we reviewed.
• There was an inconsistent approach to the application and monitoring of transdermal therapeutic pain relief and nursing staff did not always complete food and fluid balance charts accurately or contemporaneously. This meant the nutritional status of patients was not always accurate.
• Staff did not complete and update risk assessments for venous thromboembolism (VTE) for every patient.
• There was inconsistency in the management of staff competencies across the medical service.

Updated 8 January 2020

We rated it as outstanding because:

• We rated safe, effective and caring as good. We rated responsive and well-led as outstanding.
• The service had enough staff to care for patients and keep them safe. Staff understood how to protect patients from abuse. The service managed patient risk well. The design and use of facilities, premises and equipment kept people safe. The service managed safety incidents well and learned lessons from them.
• The service undertook regular audits and discussed these at leadership meetings to improve the service. Leaders ensured that staff received appraisals. The service provided care and treatment in a multidisciplinary way both internally and externally.
• Staff cared for and showed respect to babies, children and their families. Patients and their families told us examples of staff providing compassionate care. Staff informed children and their families and made them partners in their own care, and provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and sought feedback from children and their families. Children could access the service when they needed it and did not have to wait too long for treatment. The service ensured that children’s education did not fall behind when children had to spend extended time in hospital.
• Leaders had good oversight of the service. There were governance processes in place to monitor the service and risks were well managed. Staff felt respected and worked well with their colleagues on all levels.

Updated 8 January 2020

Our rating of this service went down. We rated it as requires improvement because:

• The service was not regularly monitoring the quality of records or medicines management through audit activity. Mandatory training completion rates for medical staff was not always meeting the trust target. The unit did not have a formalised process for carrying out risk assessments for patients thought to be at risk of self-harm or suicide and had not carried out an environmental risk assessment for ligatures. Staffing levels did not always meet national guidance. Safety checks of transfer equipment were not always carried out in accordance with policy.
• Staff were not always carrying out mental capacity assessments when required or clearly recording information about consent or best interest decisions in the patients’ records. Improvements as a result of audits were not always checked and monitored. Access to multi-disciplinary team members was not always in line with national guidelines. Appraisal rates were below the trust target and the number of nurses in possession of a post registration award in critical care was not in line with national guidance.
• The service was not always managing information effectively. There was not always a systematic programme of clinical and internal audit to monitor quality, operational and financial processes. Arrangements for identifying, recording and managing risks, issues and mitigating actions were not always effective. Leaders had not always ensured that learning from external reviews, audits, incidents, or mortality and morbidity reviews was used to make improvements in a timely manner.

However,

• Staff were highly motivated to offer care that was kind and promoted people’s dignity. We were provided with a range of examples of staff going above and beyond to provide compassionate care to patients and relatives. Staff took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.

Updated 8 January 2020

We rated the service as good because:

• The service had enough nursing staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to live well until they died, supported them to make decisions about their care, and had access to good information.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the specialist palliative care service when they needed it and did not have to wait too long for treatment.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and staff to plan and manage services and all staff were committed to improving services continually.

Updated 16 June 2021

Updated 8 January 2020

• Staff did not always consistently complete mandatory, safeguarding and mental capacity Act training in line with trust targets.
• The service did not consistently manage safety incidents well and lessons from them were not embedded across the service.
• Records were not stored securely on some wards.
• None of the surgery staff groups met the trust target for appraisals.
• People could not always access the service when they needed it and occasionally had to wait too long for treatment.

However,

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They mostly managed medicines well.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

Updated 8 January 2020

We rated it as requires improvement because:

• The service did not control infection risk well. Staff did not use control measures consistently to protect patients, themselves and others from infection. Effective processes were not in place to indicate when equipment was clean and ready for use.
• The design, maintenance and use of facilities, premises and equipment did not always keep people safe, particularly patients with mental health needs. Staff did not always have access to the equipment they required to keep patients safe, such as quick access to ligature cutting devices. Medical equipment stores were not always appropriately secured to protect patients from harm.
• Staff did not always complete environmental risk assessments for each patient swiftly, particularly for patients with mental health needs. Staff did not always remove or minimise risks and update the assessments. Managers did not always identify all potential risks within the department and did not always manage them effectively.
• Staff did not always identify and quickly act upon patients at risk of deterioration. Early warning scores were not always taken and acted upon correctly. Patients were not always monitored appropriately. Patient observations were not always undertaken when required and were not always escalated for clinical review. Patients were not always placed in the most appropriate cubicle for their condition and current presentation.
• Staff did not keep detailed records of patients’ care and treatment. Paper records were not always clear, up-to-date or stored securely. Documents used to record patients’ consent to treatment, fluid intake and nutrition levels were not fit for purpose. Staff did not always ensure electronic patient record systems were correctly locked when not in use to prevent unauthorised access.
• Leaders did not always operate effective governance processes throughout the service. Staff were not always clear about their roles and accountabilities. There was not always sufficient accountability for patients in ambulatory care and for patients held in corridors.
• Staff did not always have regular opportunities to meet, discuss and learn from the performance of the service.
• The service did not always use systems and processes to safely store medicines.
• Managers did not ensure patient feedback was actively captured within the department.

However:

• The department worked well with the hospital frailty teams to ensure patients who were frail received care that was tailored for their needs. This included a dedicated frailty nurse who worked with the department and helped inform on any patient discharge decision.
• The service managed patient safety incidents well. Staff recognised incidents and near misses and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Managers ensured that actions from patient safety alerts were implemented and monitored.
• Leaders had the integrity, skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles.
• Staff treated patients with compassion and kindness and took account of their individual needs. Staff provided emotional support to patients, families and carers to minimise their distress. They supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment.
• Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear.
• All staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation and participation in research.