What we have done to make care safer
What we have done to make maternity care safer for you.
A message from the Director of Midwifery
Background of our CQC Journey
April 2022
In April 2022, Gloucestershire maternity services was rated inadequate by the Quality Care Commission (CQC) after previously being rated good..
The CQC is an independent (not part of the NHS) organisation that reviews health and adult social care in England to make sure services provide safe, effective, compassionate, high-quality care and they encourage care services to improve.
The CQC monitors, inspects and regulates services and publishes what they find. Where they find poor care, they can use their powers to take action.
You can read the report about our maternity service here.
The CQC looks at five areas of our service in order to give us a rating. They inspect whether our service is:
- Safe
- Effective
- Caring
- Responsive
- Well-led
The reason maternity services in Gloucestershire were rated inadequate was because the CQC felt we needed to improve our performance in two areas: safe and well-led. In the areas of effective, caring and responsive, we were rated good.
The areas of concern were in governance and staffing.
- Staff (particularly agency staff) knowledge and experience of Trust systems.
- Sharing of learning from incidents
- 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.
- Processes were not effective enough to consistently identify and embed good practices.
- 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.
Because of these concerns, the CQC issued our maternity services with a section 29A Warning Notice
The CQC did note in this visit that responses to Friends and Family surveys showed over 85% of people who used the service had a positive experience.
After an inspection, the CQC will always produce a report. They can in addition issue ‘enforcement notices’ where it is felt the pace of progress is insufficient, or there is felt to be a more immediate issue.
April 2023
In April 2023, the CQC came to inspect our services again but despite the improvement work we had done over the last year, the evidence we provided of stronger reporting processes and shared learning, they felt further work was still needed and our rating remained inadequate.
The CQC issued an updated section 29A Warning Notice
March 2024
The CQC inspected our Maternity Services again on 26 March 2024. They provided initial feedback that there were no immediate safety concerns and that improvements had made in the culture within the department. They also requested a range of further information about service developments.
Despite the work we had already been doing to strengthen reporting process, and the way learning was shared, it was identified that further work was still needed in these areas.
As a result, the CQC notified us in May 2024 that a section 31 enforcement notice would be issued. As the service had been issued with a section 29a warning notice previously, this is the next step in the CQC process. A number of reporting conditions were put in place to ensure we focused our attention and increased the speed of change, including:
- Stronger systems to provide and up to date and overarching view of quality and safety across the maternity service;
- Systems and processes to identify and action timely identification and learning from incidents across all teams in the department.
These include immediate actions that the Trust is expected to take, and the service is required to report progress to the CQC on a monthly basis. There is additional system oversight and coordination in place so we can ensure that improvements that need to be made are embedded.
The maternity service is also reviewing internal process so there is an effective system of governance, aligned to Board reporting, to ensure improvements, are acted upon and shared in a timely way. This includes oversight of themes and trends from incidents and feedback.
Changes we have made to make care safer for you
New leadership structure
We appointed a Director of Midwifery to our divisional leadership team and we have a perinatal quad (four people) to oversee maternity and neonatal services. We have also increased staff numbers in other key areas of matrons, patient safety teams, obstetric consultants, education teams. You can read more about our maternity leadership team.
Recruited more staff
Since October 2024 we have welcomed 41 new midwives into our service and two consultant obstetricians, and we are continuing to recruit into our maternity workforce. We focus on providing a kind, caring and compassionate workforce who are committed to making a difference to your pregnancy journey and birth experience. To understand the impact of safe staffing on all aspects of maternity care, our staffing reports show our national and regional compliance with key metrics: 1:1 care in labour, birth to midwife ratio; and supernumerary status of the labour ward coordinator (midwife in charge of the unit).
We hold a daily maternity flow meeting to ensure we have the right midwives in the right place to ensure you are safe and to escalate when needed to senior staff when a shortfall is anticipated. We also use a nationally established tool to look at the complexity of the women in our care at any one time so we can plan staffing based on need. Our midwifery workforce is flexible, which ensures that women have the right care at the right time putting safety and the experience of our families at the heart of our decisions.
Managing a bleed after birth
We are now using a nationally developed process which is considered best practice for reducing major bleeding after birth. It identifies women at risk of bleeding and provides a more consistent measure of blood loss allowing us to respond quicker when someone is bleeding abnormally. This means where possible we can try and avoid someone needing a blood transfusion and a longer stay in hospital.
Following national guidance for fetal monitoring
We monitor your baby during pregnancy through both scans and at antenatal appointments. During labour we either use continuous monitoring of your baby, or we use a hand held doppler to listen at regular intervals. The decision on the most appropriate way to monitor your baby in labour is made with you at the beginning and during labour.
We are committed to ensuring we have the correct processes in place for this and we have a dedicated fetal wellbeing lead midwife to review our fetal monitoring practices regularly, analyse trends and support staff to improve confidence and knowledge of fetal monitoring. Our teams learning together at a fetal wellbeing study day, receive teaching on the wards, receive regular learning updates through our ‘Fetal Wellbeing Wednesday’ email and our fetal wellbeing lead midwife is available for 1-2-1s.
Improving how we monitor patients in danger of deteriorating
We use a chart called a maternity early obstetric warning score (MEOWS) to help us know if a patient's condition is getting worse by giving them a score of green, amber or red. When we reviewed how we used these charts, we found every area had different challenges with compliance. We worked as a team to improve compliance across all areas of maternity, during the antepartum, intrapartum and postpartum periods.
Better induction of agency staff
We have implemented a comprehensive induction to the unit to make sure agency staff are fully instructed and able to work alongside our Gloucester team to provide the best care.
Created a perinatal dashboard
The perinatal dashboard is a digital tool created by our Business Intelligence Hub. It uses key data to help us track trends over time and in comparison with national metrics. We have expanded it to include a maternal morbidity and mortality section.
A new governance structure
Behind the scenes, we have created a new structure of groups and forums which improve patient safety by being ‘clinically led and data fed’. By increasing active participation by staff and focusing on clinical leadership and data we have improved transparency and communication between staff groups and prioritised expertise and evidence.
Safety Champions
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. Our staff are encouraged to attend these so that they feel that their voice is heard. You can find out who our safety champions are here.
Reviewing scan capacity and delays
To help us understand why delays happen we have completed a review to look at whether current capacity (available clinic slots) meets demand (the number of patients requiring care). This helps us identify where the issues are that we need to tackle next
Electronic access to your maternity notes
We now have a single electronic patient record system across all of our maternity services which means wherever you access care in Gloucestershire, our clinical teams will have instant access to your notes. It also has a patient online portal and app where you can read your notes, input your own messages, track weekly development through your pregnancy and view some test results. To find out more about this, visit our Badger Notes page
Supporting you through pregnancy and beyond
We continue to strengthen our partnerships with key voluntary sector organisations to better work together to support women, birthing people and their families during pregnancy and as they transition away from maternity or neonatal care. We also work closely with the Maternity and Neonatal Voices Partnerships (MNVPs) in Gloucestershire and the South West. You can contact MNVP to share anything about our service.
The Real Birth Company provides an online birth preparation course that has modules such as: Thoughts and Feelings around Birth; The Pelvis and Labour; Practical Birthing Skills; Caesarean Birth; Giving Birth to Your Baby Early and so much more!
Improving blood clot risk assessments
Thrombosis and Embolism (blood clots) continue to be the leading cause of direct maternal deaths occurring within 42 days of the end of the pregnancy (MMBRACE 2019-2021). We risk assess you throughout your pregnancy and postnatal period. When we identify risks, we recommend preventative treatments tailored to your individual needs. We continuously monitor our compliance with these actions to maintain your safety.
A good safety culture
We have been improving the culture for raising concerns so that all staff know how to raise a concern is they are worried about the safety of our service. This includes making our Freedom to Speak Up service more visible and having safety champions who regularly visit all areas and who staff can raise concerns with. We have also introduced the role of ‘flow midwife’ who reviews staffing and activity levels across the unit and improve our safe staffing levels.
In line with other trusts, we are using a new patient safety framework from NHSE called PSIRF. Our focus is on sharing learning from our maternity incidences with our teams to ensure we make changes to improve our service.
Patient Experience Group
We have a Patient Experience Group which meets monthly to discuss concerns and compliments from our service users and their families promptly so we can address problems and build on our strengths.