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Liverpool Women's NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Requires improvement read more about inspection ratings

All Inspections

24 to 25 January 21,22,23 February 2023

During a routine inspection

Liverpool Women’s NHS Foundation Trust is a specialist trust that specialises in the health of women, babies, and their families. It is one of only two specialist trusts in the UK and the largest women’s hospital in Europe. As a tertiary centre the hospital provides care for a significant proportion of patients with high levels of complexity and clinical risk, as well as serving a local population with significant deprivation. The hospital teams deliver around 8,000 babies and perform some 10,000 gynaecological procedures each year.

The trust is situated in an area where 44% of the population live in the lowest quintile for deprivation in England. 26% children (0-15 years) live in poverty. The region performs significantly worse for premature cancer, cardiovascular disease (CVD) and respiratory deaths. 46% of women booking with Liverpool Womens Hospital are from the 1st decile on the deprivation index, compared to a national average of 13%

The maternity team cares for women and their babies from conception to birth supported by the neonatal team who provide around the clock care for premature and new-born babies needing specialist care.

The trust’s fertility team helps families to improve the chance of conceiving babies. Community midwifery teams were based in areas of deprivation.

In gynaecology, the trust undertakes care of women with the many varied conditions associated with the female reproductive system and is a centre for gynaecology oncology. The genetics team supports families with the diagnosis and counselling of genetic conditions. The trust also carries out gynaecology operations including surgical termination of pregnancy.

The new Community Diagnostic Centre (CDC) at the hospital includes a mobile CT scanner. At the Crown Street site, the CDC has a new colposcopy suite, CT, and MRI imaging facilities.

We carried out an unannounced inspection of the gynaecology services provided by this trust.

A focused inspection of maternity services was also carried out as part of the CQC national maternity inspection programme which looked only at the safe and well led questions. We also inspected the well-led key question for the trust overall.

We did not inspect neonatal services, end of life care or outpatients, using our ratings principles the ratings for these services have been aggregated from the inspection in 2019.

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

We rated safe and well led as requires improvement. We rated caring, effective and responsive as good. We rated one of the trust’s services as requires improvement and one as good.

Overall, the trust leadership team had knowledge of the main priorities and challenges faced by the service for the future but did not always understand and manage the immediate priorities and issues the service faced.

Although there were governance processes, throughout the service and with partner organisations, these processes were not always managed effectively.

Not all staff felt respected, supported, and valued. However, they remained focused on the needs of patients receiving care. Some staff had raised concerns several times regarding safety and staffing directly to senior leaders however they saw no quick action or improvement.

Leaders and teams did not always use systems to manage performance effectively. They did not always identify and escalate relevant risks and issues with effective actions to reduce their impact.

The trust collected and analysed data however it did not always act on it in a timely way. Not all staff could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. Data or notifications were not always consistently submitted to external organisations as required.

However:

The trust had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. The vision and strategy were focused on sustainability of services and aligned to local plans within the wider health economy.

The service had an open culture where patients, their families and staff could raise concerns without fear. Although in maternity services some women and birthing people gave negative feedback about their experience of care.

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.

The trust promoted equality and diversity in daily work and provided opportunities for career development. The equality, diversity, and inclusion networks had been refreshed. The PRIDE (LBGTQ+) Network was more recently established and was developing.

The trust had plans to cope with unexpected events.

The information systems were integrated and secure.

Staff were committed to continually learning and improving services. Leaders encouraged innovation and participation in research.

How we carried out the inspection

During our inspection of maternity services, we spoke with staff including midwives, student midwives and doctors, maternity support workers, midwifery matrons, junior doctors, middle grade obstetricians, consultant obstetricians, as well as administration and clerical staff and senior managers. We spoke to 9 women. In gynaecology we spoke with 4 women and 41 members of staff we also looked at 15 patient records.

We conducted focus group meetings with staff prior to the inspection and during the core service inspection.

The inspection was overseen by Karen Knapton the interim deputy director and included an inspection manager, inspectors, and specialist advisers. An executive reviewer supported our inspection of well-led for the trust overall. Executive reviewers are senior healthcare managers who support our inspections of the leadership of trusts. Specialist advisers are experts in their field who we do not directly employ.

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

29 Jan to 28 Feb 2018

During a routine inspection

Our rating of the trust stayed the same. We rated it as good because:

  • Safety systems, processes and standard operating procedures were reliable or appropriate to keep women and babies safe. Staff followed policies and national guidance.
  • The trust assessed patient risk well. Staff identified risks to patients and took appropriate measures to mitigate these risks.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • The service had enough staff with the right qualifications, skills, experience and training to keep patients safe from avoidable harm and abuse, and to provide them with the care and treatment they needed. Ward managers matched staffing levels to patient need and could increase staffing when care demands rose by rotation of staff.
  • The trust provided specialist clinics and staff with enhances skills to support women with special needs.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • There was an established Maternity Services Liaison Committee (MSLC), which provided an effective channel for users of maternity service to influence the local provision of maternity services.
  • The trust had managers with the right skills and abilities to run a service providing high-quality sustainable care.
  • Community staff made prompt and timely referrals for women and babies that were identified as vulnerable and there was evidence that the trust worked closely with the enhanced midwifery team, safeguarding team and social services.
  • The maternity service had an escalation policy whereby on-call community midwives were required to provide additional staffing to the hospital.
  • There were regular divisional and managerial meetings to discuss all incidents in maternity services, including progress on investigations. Feedback to staff was given via face-to-face discussions, emails, staff handovers, staff huddles and team meetings.
  • The trust used a combination of National Institute for Health and Care Excellence (NICE) and Royal Colleges' guidance to determine the treatment provided such as supporting a home or water birth and women who did not attend appointments.
  • Parents were involved in choices about their baby’s birth both at booking and throughout the antenatal period. Those we spoke with said they had felt involved in their care; they understood the choices open to them and were given options of where to have their baby.

However:

  • We found that some governance structures, processes and initiatives were recently developed and had yet to be fully embedded and audited in practice.
  • Community managers informed us that they completed a training and development log for all their community midwives for mandatory training requirements. However, they did not have complete oversight or use a scoping tool to assess when midwives last undertook a homebirth, pool birth or when community midwives last sutured following a delivery.
  • Staff did not always have access to up-to-date, accurate and comprehensive information on patients’ care and treatment. All staff had access to an electronic records system that they could all update however there were many systems in current use which made it laborious and difficult to access information quickly.
  • Within the gynaecology core service we found that staff did not always take time to interact with patients outside of essential conversations during observations or examinations.
  • Maternity Early Warning score (MEWS) audit results in 2017 were overall good. However, some areas scored low or were scored as “not applicable”. This highlighted some inconsistencies with either the staff completing the MEWS incompletely or issues with the audit process.
  • Computer information systems needed to be enhanced, streamlined and developed further to reduce and mitigate risks.

18 - 19 February and 4 March 2015

During a routine inspection

Liverpool Women’s NHS Foundation Trust provides a range of specialist services for women including inpatient and community maternity services that deliver approximately 8,000 babies a year, a neonatal service to support newborn babies needing specialist care, obstetrics, gynaecology, gynaecology oncology, termination of pregnancy and a unique emergency room for patients who have urgent gynaecological problems or for women with problems in early pregnancy (at fewer than 16 weeks). The trust is also a major obstetrics, gynaecology and neonatology research hospital, one of only two specialist trusts in the UK, and the largest women’s hospital of its kind in Europe.

Liverpool Women’s NHS Foundation Trust serves more than 30,000 patients from Liverpool, the surrounding areas and across the UK.

We carried out this inspection as part of our comprehensive inspection programme.

We carried out an announced inspection of the trust on 18 and 19 February 2015, and we undertook an unannounced inspection between 4pm and 7pm on 4 March 2015. As part of the unannounced visit, we looked at maternity and surgical services.

We rated Liverpool Women’s NHS Foundation Trust as good overall, although we found that the community midwifery service required improvement. The trust was developing plans to reconfigure and integrate the community service at the time of our inspection.

The trust had a vision ‘To be the recognised leader in healthcare for women, babies and their families’. This vision underpinned all the trust’s strategies and plans. The vision and values were well known throughout the organisation. The values were represented in all key documents and strategies as well as being embedded in the staff appraisal process. The trust had recently reviewed its quality strategy and the revised strategy had received board approval in February 2015. All agreed priorities had clear and measurable indicators for success that were subject to regular monitoring and review.

All staff were aware of the trust’s priorities and challenges, and understood the plans and actions needed to address them.

After our previous inspections in April and September 2014, the trust made significant improvements to its governance and risk management systems. Governance and risk management systems were more robust and provide good information and assurance in respect of performance and risks.

The senior team was visible and accessible to staff, and managers were seen by staff as supportive and approachable. There were some concerns about the leadership style on the labour ward that managers were committed to exploring and addressing.

Staff were committed and passionate about their work. They were keen to learn and continuously improve the services they offered to patients.

There was a positive and enthusiastic culture throughout the trust. Staff were proud of the services they offered and the work they did.

The trust was open about its financial challenges and was working with commissioners and other key stakeholders to seek solutions that would improve its financial position and secure the future sustainability of services.

Cleanliness and infection prevention and control

  • Patients received care in a visibly clean and suitably maintained environment. There was a high standard of cleanliness throughout the trust. Staff were aware of current infection prevention and control guidelines. They were supported by staff training and the adequate provision of facilities and equipment to manage infection risks.
  • There were good rates of compliance recorded in hygiene audits across all services provided by the trust.
  • Infection rates were low, and staff were proactive and vigilant in the prevention and control of infection.

Incident reporting

  • There were established systems for reporting incidents and ‘near misses’. Staff had received training and were confident in the use of the incident reporting system. The latest national reporting and learning system (NRLS) data (September 2014) stated that the organisation had a reporting rate of 68.48 per 1000 bed days, which was higher than the median of 35.92 for the cluster of acute specialist trusts. The trust were in the highest 25% of reporters. The trust was however slow to upload incidents to the NRLS system with 50% of incidents submitted more than 41 days after the incident had occurred.
  • The reporting culture had improved from the previous reporting period. The trust had worked with its staff teams to address this issue and to encourage and support staff to report all incidents appropriately. Managers realised that a low patient safety incident reporting culture could hinder staff in identifying risks and the trust in taking action to prevent avoidable harm to patients.

Safeguarding

  • The systems, policies and procedures for safeguarding children were robust, well understood and supported by staff training. All relevant staff had received child safeguarding training. There were good examples of staff acting promptly and appropriately to secure the safety and welfare of children.
  • However, the trust had identified that adult safeguarding was less well developed. In response, a comprehensive staff training programme for the safeguarding of vulnerable adults had recently been introduced. Staff were developing their understanding, competency and knowledge in this area at the time of our inspection. Staff training figures indicated that, by March 2015, 95% of relevant staff would have received adult safeguarding training.
  • Safeguarding practice was supported by a trust-wide safeguarding team that staff could access for advice and support. However, at the time of our inspection there appeared to be an over-reliance on these key individuals as opposed to sustainable systems and processes to safeguard adults. Also, we found some examples in the surgical service indicating that the approach to the safeguarding of adults needed further development.
  • The trust acknowledged at board level that the adult safeguarding systems were not yet robust, and it increased the level of risk on the board assurance framework in relation to safeguarding in December 2014.
  • The trust had developed comprehensive plans to address the identified gaps in training and practice.

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Nurse and Midwifery staffing

  • Nurses and midwives were caring and compassionate. They treated patients and those close to them with dignity and respect, and they were committed to giving patients a high standard of care and treatment. Appropriate staffing levels were calculated using a recognised tool and regularly reviewed.
  • Since our last inspection, there had been a significant increase in the numbers of nurses and midwives employed, and there were now sufficient numbers to meet the needs of patients in all the core services we inspected. There were plans to increase the number of neonatal nurses to meet the British Association of Perinatal Medicine (BAPM) standards. At the time of our inspection, staffing was sufficient to meet the needs of babies being cared for because current neonatal staff were working extra hours to fill gaps in the staffing rota.
  • The neonatal service had introduced the Advanced Neonatal Nurse Practitioner (ANNP) role. The ANNPs were having a positive effect in supporting high-quality care for babies needing specialist neonatal support. However, it was acknowledged that more work was required to fully embed and integrate this key role within the service.

Medical staffing

  • Medical treatment was delivered by skilled and committed medical staff. There were excellent examples of senior doctors providing strong leadership and being actively engaged in the design and development of services.
  • There were sufficient numbers of consultants and middle grade doctors to provide good quality care and treatment for patients; however, in maternity – inpatient services, the consultant cover was only 77 hours, which was lower than the 98 hours minimum recommended by the Royal College of Obstetrics and Gynaecology for a unit this size. Junior medical staff were well supported and provided with excellent teaching and learning opportunities.
  • The tier 1/middle-grade staffing levels were acceptable in terms of establishment but the neonatal unit often operated below the required level. In response to this, the service had introduced an ANNP role to help junior doctors working in the unit.

Mandatory training

  • The trust had set targets of 95% and 90% for mandatory training and appraisals, respectively. These targets were not yet being achieved at the time of our inspection. The overall compliance figures reported to the trust board in January 2015 was 91% for mandatory training and 86% for appraisals. There were plans to increase completion rates by the end of the performance year.

Nutrition and hydration

  • Patients’ religious and cultural needs were considered and food was provided in accordance with their requirements. Staff gave appropriate and discreet support to those patients who needed help with eating and drinking. Specialist dietary support was available to patients whose condition indicated or required a specialist diet.
  • The trust had a team of midwives, support workers and infant feeding advisers who helped women to feed their babies. The maternity and neonatal teams were supported by Liverpool Babies & Mums Breastfeeding Information and Support (BAMBIS), a team of peer supporters who offered breastfeeding support and information to pregnant women, breastfeeding mothers and their families.

Outcomes and evidence-based care

  • Care and treatment were delivered throughout the trust in accordance with evidence-based guidelines. The trust had a system for receiving, recording, assessing and monitoring compliance with guidance from the National Institute for Health and Care Excellence (NICE). Quarterly reports were provided for commissioners as part of the quality contract requirements, with internal mechanisms monitoring compliance at divisional and trust-wide levels. When guidance could not be implemented in full (for example, if other healthcare providers were involved as part of the patient pathway), this was risk assessed for inclusion on the risk register and in the monitoring reports.
  • Maternity outcomes were monitored using a local maternity dashboard and Royal College of Obstetrics and Gynaecology indicators. These monitored key outcomes, such as methods of delivery, still-birth and neonatal death, epidural rates and the number of women receiving-one-to one care during labour. Clinical outcomes in Maternity services were comparable with or better than, those of similar services.
  • In gynaecology services senior staff took part in national and local audits to ensure that they were providing care in line with recognised standards. These included the national menorrhagia audit and a local audit to investigate the recurrence rate of infections with Bartholin’s gland surgery. The results were comparable with other similar organisations.
  • Surgical site infection rates were compared with a peer trust for the 12-month period up to December 2014; the trust was better than or equal to the peer trust on all but one type of infection.
  • Care for end of life patients was based on the National Institute for Health and Care Excellence (NICE) guidance. The trust had reviewed its own processes in response to the national review of the Liverpool Care Pathway and produced end of life care guidance for staff
  • The neonatal services used a combination of guidelines from National Institute for Health and Care Excellence (NICE), British Association of Perinatal Medicine (BAPM) and Royal Colleges’ to determine the care and treatment provided.
  • The service benchmarked patient outcomes against similar units in the UK and the USA. Outcomes compared well with other neonatal services. There was also benchmarking against similar units for mortality and morbidity rates. There was evidence that mortality rates were within acceptable ranges and were continuing to decline. Infection rates had also declined and compared well to similar units.

Access to services

  • The trust consistently met most of the access targets. These included referral to treatment times in all specialties, booking midwife visits before 12 weeks and foetal anomaly scans between 18 and 20 weeks, and the cancer targets of 31 and 62 days.
  • The trust did not always achieve the 60 minute targets for treatment in its emergency gynaecology service; however, the trust consistently achieved the national 4 hourly access target for emergency departments. Managers were of the opinion that the target for all acute emergency departments was not necessarily the best measure for a specialist department of this nature.

Governance risk and management and quality measurement

  • After our previous inspections in April and September 2014, the trust made significant improvements to its governance and risk management systems. The board assurance framework was now a live document that was well understood by the board. The framework was set out under the trust’s strategic aims, and had good risk descriptions with clear details of the risk, cause, effect and impact. There was good alignment with the risk register. In addition, controls were appropriate and there were good examples of assurance sources.
  • The newly approved quality strategy detailed the quality governance arrangements for the trust and the new arrangements were being implemented at the time of our inspection. The trust had recently introduced a ‘patient experience senate’ as part of its quality governance arrangements, and it had plans to introduce senates for patient safety and clinical effectiveness. All committee activity related to quality governance ultimately reported to the governance and clinical assurance committee that in turn reported to the trust board. Attendance at some of the committees, such as the corporate risk committee, could have been improved: some members had only attended 4 of the past 9 committee meetings.
  • The trust had been an outlier in for its data quality on a number of occasions (CQC ‘Intelligent Monitoring’ reports). A dedicated data quality committee was now in place to provide challenge and assurance in this regard. A ‘gatekeeping’ policy had been introduced for secondary uses (SUS) data to ensure that all data was validated before leaving the organisation. We were unable to ascertain the impact of this work at the time of our inspection; however, the trust was confident that data quality would improve as a result of the actions taken.

Innovation, improvement and sustainability

  • The trust was a major obstetrics, gynaecology and neonatology research hospital and there was a wide range of ongoing research projects at the time of our inspection.
  • There were examples of innovative and outstanding practice for example; the neonatal unit was the first unit in the country to put the HeRo System in practice. This was a monitoring system that monitored the variability in babies heartbeats that helped with the early diagnosis of infections and other complications.
  • The trust acknowledged that it was not financially sustainable in its current structure. It was working with partners in ‘Healthy Liverpool’ (a system wide project with aims to provide a new health and social care system to transform the health of Liverpool citizens). to discuss proposals for the future and how service provision can be developed and sustained.

We saw several areas of outstanding practice including:

  • The implementation of the HeRo system. The neonatal unit was the first in the country to put this system into practice.
  • The neonatal unit’s benchmarking of its practice and outcomes against other units in the UK and the USA.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Improve the way in which medicines are managed and stored.
  • Check the folder of medication data sheets in each room within the neonatal unit at more regular intervals; and confirm with a signature that they have been checked and are valid.
  • Store the portable box containing emergency medicines in the high dependency unit securely.
  • Provide appropriate neonatal resuscitation equipment in the maternity assessment unit.
  • Provide effective controls to prevent the abduction of infants from the labour ward and the Catharine Medical Centre.
  • Ensure that risks regarding the storage of formula milk are appropriately assessed, and effective controls implemented to manage those risks.
  • Provide operating department practitioners or suitably qualified midwives in theatre recovery outside normal working hours.
  • Ensure that the telephone triage line is staffed at all times.
  • Ensure that, when restraint is necessary, it is undertaken in accordance with the relevant regulations and legislation.
  • Ensure that paper medical records are of an adequate standard and provide accurate, up-to-date records of the consent, care and treatment provided.
  • Ensure that all staff are able to safeguard adults appropriately.

In addition the trust should:

  • Review the number of hours of consultant cover in maternity, which were lower than the recommended minimum from the Royal College of Obstetrics and Gynaecology for a unit this size.
  • Ensure that issues identified during audits are addressed.
  • Review the numbers of incidents reported in all services.
  • Ensure that domestic violence referrals from the police are reviewed within agreed timescales.
  • Review practice with regard to the artificial rupture of membranes during induction of labour.
  • Improve the response rates for the NHS Friends and Family Test.
  • Consider including emergency appointments in the induction suite diary.
  • Ensure that there is an effective system in place for testing portable electrical appliances.
  • Allocate a non-executive director with responsibility for termination of pregnancy services.
  • Review the timing of resuscitation decisions so that discussions are initiated with patients at a time when they are well enough to fully consider their wishes.
  • Initiate work on advanced care planning with patients at a time when they are well enough to fully consider their wishes.
  • Monitor the quality of care planning on the wards against patients’ assessed needs.
  • Provide dementia training for ward staff.
  • Address the leadership issues and staff morale within the intrapartum areas.
  • Address the role of the advanced neo-natal practitioners (ANNPs) so they are clear how it fits within the service and take steps to involve them in developments in the neonatal service.
  • Consider the provision of newborn life support training for community midwives.
  • Consider auditing the availability of patient records.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.