The Care Quality Commission (CQC) has welcomed improvements in the maternity services at Royal Free Hospital and Barnet General Hospital, provided by Royal Free London NHS Foundation Trust following two inspections.
In May, CQC carried out an unannounced focused inspection of maternity services at Royal Free Hospital to follow up on concerns identified during a previous inspection in October, when the service was rated inadequate overall. Following this inspection, the overall rating of the service improved from inadequate to requires improvement.
This was followed by an unannounced focused inspection of maternity services at Barnet General Hospital in June, after receiving information of concern about the quality and safety of the service. As this was a focused inspection, the service has not been re-rated and retains its rating of good. Inspectors looked at how safe, effective and well-led the service was, and found that the trust had made improvements at Barnet General Hospital, based on learning from changes made at Royal Free Hospital.
Nicola Wise, CQC’s head of hospital inspection, said:
“I am pleased to report that trust leaders have made progress in addressing the concerns we identified in our previous inspection of maternity services at the Royal Free Hospital, and this learning has been shared across the trust, so we also saw improvements at Barnet General Hospital. This is good news for women and their families who are using these services.
“Our inspectors found an open culture of learning and continuous improvement, where staff are encouraged to report incidents and feel supported when they do. This ‘no blame’ culture benefits everyone.
“Quality improvement initiatives are also encouraged. One of these resulted in the idea of providing knitted orange hats for vulnerable babies so that staff could easily see which babies needed extra support, which is a really commendable initiative.
“However, there is still more work to be done, especially around tackling health inequalities experienced by disadvantaged groups. Although the trust had taken some action including access to information in other languages, there wasn’t enough focus on understanding and addressing health inequalities and outcomes. Staff at the Royal Free Hospital told us that women complained about not being treated the same as other women because of their ethnicity, yet little had been done to learn from this feedback, which told us people’s cultural and social needs weren’t being met. This is not acceptable, and leaders need to act quickly to ensure that it is addressed.
“We have pointed out some further areas for improvement and we will follow up to see that these are addressed when we return to reinspect the service.”
Royal Free Hospital was rated requires improvement for the following reasons:
- The service did not always make sure staff were competent for their roles. Although most staff were experienced, qualified and had the right skills, some midwives did not have the skills required to work in the labour ward, or were not confident with carrying out certain procedures
- The service still had limited knowledge of the local population. Further work was needed to connect with women from diverse backgrounds and to address health inequalities
- The service needs to improve how it engages with staff and patients
- There was limited out of hours and weekend support for breastfeeding.
However, since the last inspection the Royal Free Hospital had made significant improvements in several areas:
- Governance processes had been improved with clearer accountability and more multidisciplinary work, which will improve outcomes for the women using this service
- The service had improved the way it shared learning with staff meaning they could learn from previous incidents to prevent them from happening again
- Duty of Candour processes were in line with national guidance. These require healthcare professionals to be open and honest with patients and to apologise to them when something goes wrong with their treatment, or their care causes, or has the potential to cause harm or distress
- The service had improved IT systems and equipment, which benefitted women using the service, as staff had up to date information on their needs, although the work was still ongoing to make further improvements.
At Barnet General Hospital, inspectors found:
- Leaders had improved processes for them to oversee how effectively services were running, making it easier to address problems as they arose. There were also more effective processes for staff to follow during their daily work as well as how the service involved partner organisations to benefit people using the service
- Managers identified any training needs their staff had and gave them the time and opportunity to develop their skills and knowledge. The trust recently won the capital midwife quality mark for delivering a program that continued to support and develop new midwives’ knowledge and skills. Midwifery and support staff kept up to date with their mandatory training, which was comprehensive, giving staff the knowledge they needed to keep people safe Staff knew how to identify adults and children at risk of abuse or suffering from significant harm and worked with other agencies to protect them
- Managers and staff carried out a comprehensive programme of repeated audits to check improvement over time
- Staff completed and updated risk assessments for each woman and took action to remove or minimise risks. Staff identified and quickly acted upon women at risk of deterioration
- Safety incidents were managed well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave women honest information and suitable support. Managers ensured that actions from patient safety alerts were implemented and monitored
- Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service
- Key patient safety information was available in other languages. Information on how to leave feedback was clearly displayed in all service areas
- Most staff were positive about their work, relationships with colleagues, support from managers and development opportunities.
However, at Barnet General Hospital, inspectors also found:
- Birthing pool cleaning was not routinely audited, which meant the service could not have full assurance that women and babies were kept safe from infection
- Staff said that delays in medical reviews would often affect the timely management and treatment of women and that service managers did not audit wait times regularly
- Some records were paper only and detailed medical records, which contained the mother’s medical history, were not available at booking in appointments
- Daily cross-site huddles were not always attended by the delivery suite consultants and co-ordinators at the unit which meant they were not involved with planning the day’s activity throughout the unit. This was not in line with national guidance
- Managers did not routinely monitor wait times in the maternity day assessment unit. Staff said that delays in medical reviews would often affect the timely management and treatment of women and that service managers did not audit wait times regularly.
Full details of the inspection are given in the report published on our website.
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