Basingstoke hospital maternity unit told to improve by CQC

The Care Quality Commission (CQC) made an unannounced visit to the maternity unit at the Aldermaston Road hospital in November last year after whistle-blowers, patients, and regulatory bodies raised concerns, including that midwives were too exhausted to keep patients safe because of low staffing levels.

Read more: Hampshire hospitals maternity unit told to improve by CQC inspectors 

The CQC has dropped the rating for maternity services at Hampshire Hospitals NHS Foundation Trust (HHFT) from good to requires improvement.

Inspectors found the trust had breached regulations and has taken enforcement action, issuing a list of 13 action points the trust needs to make to improve.

The CQC found:

• Dirty equipment
• Not enough staff to keep women and babies safe
• A student midwife alone in charge of six patients
• Women and babies at risk from unauthorised visitors entering the maternity unit
• Out of date medication
• An overdose of medication given
• A broken defibrillator
• Recommendations to reduce the additional risk of Covid-19 for women from black, Asian and minority ethnic groups had not been implemented
• Delays to elective caesarean sections and inductions

The report comes after parents raised their concerns about the maternity unit with the Gazette, read more here. 

The CQC reported that the design of the maternity hospital did not always ensure the security of women and babies.

Whilst there was secure access to the antenatal ward, postnatal ward, and delivery suite via swipe cars for staff or intercom for visitors, CQC inspectors were able to access the unit on the morning of their inspection when a member of staff allowed them to enter as they left.

The report said: “The staff member did not ask for identification or our purpose to be on the unit. A member of staff also allowed us to enter the building where maternity services are located via a staff entrance without asking for identification.

"This posed a security risk for women and babies that unauthorised visitors could access the maternity unit.”

The CQC also found that guidance for managing missing babies did not outline security arrangements for the maternity service.

It found that the service did not carry out any baby abduction drills for more than a year between October 2020 and November 2021, which it said created a risk of staff not knowing the procedure.

Inspectors found that while staff followed personal infection control procedures, regular cleaning and infection control across the service was not always carried out, with some equipment found to be visibly dusty and cleaning records were not always up-to-date.

While inspectors said the environment looked “generally clean” they found cleaning schedules were not always completed and some equipment had not been cleaned.

This included equipment on the labour ward, used to provide emergency resuscitation to new-born babies, which was visibly dusty.

During the inspection, medication on a postnatal emergency trolley was found to have expired, despite the trolley being checked twice since the medicine went out of date.

“This posed a risk patients could be given expired medicine in an emergency,” the report said.

A defibrillator recorded as ‘failed’ in September – two months before the inspection – had no record of the fault or any action to resolve it.

Inspectors also found various other equipment which was not routinely checked and said: “This posed a risk that essential equipment would not be in good working order if required in an emergency.”

The CQC found that there was not enough suitable equipment to help staff safely care for women and babies.

During the visit, inspectors saw equipment being shared by two patients.

The report said there were not always enough staff to meet the needs of women and babies.

On the morning of the inspection, there were only five registered midwives on duty at the start of the shift because of staff illness, when nine were needed.

However, by 11.15am nine midwives were on shift to fill the rota.

During the visit, inspectors observed an emergency call on the labour ward which the antenatal midwife attended, leaving a student midwife alone and in charge of six patients.

It said: “This posed a risk of safety to women.”

Inspectors found staffing had a “significant impact on safety and quality of service provided to women and babies” including unsafe staffing levels on wards.

However, these risks were not identified and highlighted on the trust’s risk register.

The report said: “The incorrect reporting of red flags meant the extent of level of concern for midwifery staffing may not have been visible to the trust.”

Staff said they sometimes felt “out of their depth” with high-risk cases and unable to say no.

The CQC found a midwife responsible for the care of 11 women and 12 babies, which it said: “Posed a risk that deterioration of women and babies may not be recognised and placed additional pressure on one midwife.”

The most common reason for sickness in the maternity service was anxiety, stress, depression, and other psychiatric illness. This accounted for 22.7 per cent of the maternity service sickness.

Since the inspection the trust has increased the number of midwives required for each shift to 10 so two midwives can be on the antenatal and postnatal ward.

The CQC raised concerns regarding the treatment of sepsis and found that sepsis protocol was not triggered when a woman on the labour ward recorded two separate temperatures.

When staff handed over her care, they wrongly said she had been given antibiotics.

The maternity unit had a recent serious incident where sepsis screening and treatment did not follow trust policy.

Triage times at the maternity unit were found to not be recorded.

An audit of triage times carried out from February to April 2021 showed the service achieved the 15-minute triage time for 60 to 90 per cent of patients.

However, when the CQC visited it found staff were “extremely busy” and of the 12 patients seen that morning, only one had the time of arrival and triage recorded.

It said: “Therefore, we could not be assured that staff consistently triaged women within 15 minutes.”

Inspectors found that recommendations from the Chief Midwifery Officer for England to reduce the additional risk of Covid-19 for women from BAME groups had not been successfully implemented.

The report said: “Whilst senior staff told us posters had been displayed and community staff had checklists to identify women at increased risk, no members of staff we spoke to knew about additional measures to protect this group of women.”

Women experienced delays to elective caesarean sections, with data from the trust showing 18 were delayed in August 2021; 16 in September 2021; and 12 in October 2021.

Staff who spoke to CQC inspectors said caesarean sections were frequently delayed.

There were also delays to inductions of labour, with data showing 48 were delayed in August 2021; and 27 in both September and October 2021.

The report said: “Staff told us it was common for women to have their induction of labour delayed for two days.”

A delay of induction by more than two hours is considered a ‘red flag’ event by the National Institute for Health and Care Excellence (NICE) as a warning sign that something may be wrong with midwifery staffing.

The maternity unit had high sickness rates, with data showing that the sickness rate for registered midwives increased from 10.33 per cent in August to 10.5 per cent in September.

Of this, 3.43 per cent was Covid related.

This was above the trust’s target of three per cent and significantly higher than the sickness rate for registered nurses in the trust.

CQC inspectors found that women and babies could be at risk from inaccurate record keeping.

It observed a member of staff staying 90 minutes after their shift finished to recreate notes that appeared to have been lost.

Staff told inspectors that some babies had been given two NHS numbers.

A senior member of staff told inspectors there had been an incident where an overdose of paracetamol had been administered but was not included on the maternity risk register.

The CQC found that although medicines were stored safely and securely, there were “multiple systems for recording medicine administration which posed a risk of inaccuracies in administration”.

The CQC also found that the trust did not manage safety incidents well with staff not always given feedback.

“Serious incidents were investigated but often did not identify effective immediate and long-term actions to prevent them reoccurring,” the report said.

Inspectors reviewed a ‘red flag’ incident from September 2021 where one-to-one care could not be provided on the delivery suite.

Feedback did not highlight any immediate actions to ensure it did not reoccur.

“This could potentially discourage staff from reporting incidents,” the report said.

During the inspection, staff told the CQC of a ‘never event’ in August 2020 at the Winchester site, where a procedure was carried out without consent.

Staff told the CQC that the only learning shared was the termination of the staff member’s employment.

The maternity service reported 13 serious incidents from October 2020 to September 2021, this included one maternal death.

Eight of these incidents had been reported to the Maternity Healthcare Safety Investigation Branch.

The CQC said: “We reviewed the initial incident reports for some of these incidents and found they did not identify any immediate actions to reduce the risk of these incidents reoccurring.”

Inspectors found the rates of third and fourth degree tears were worse than the national average, with 43 reported in June 2021 per 1,000 births, compared to 25 per 1,000 births nationally.

However, inspectors observed “good team working” in the maternity wards and added: “Staff were focused on the needs of patients receiving care. They generally felt respected and valued.”

Inspectors said staff were “welcoming, friendly and helpful” and “felt pride in the support they provided each other”.

The trust has been given various actions to improve, including:

• Ensuring all staff identify and treat sepsis in a timely way
• Ensuring the environment meets national guidance and is cleaned effectively
• Ensuring regular checks on emergency and essential equipment are carried out
• Ensuring the security arrangements for the maternity unit and staff only areas of the maternity unit keep women and babies safe
• Ensuring national guidelines are followed when screening women for a risk of domestic violence
• Ensuring data is managed so it is up to date, reliable and can aid decisions about risk and performance in the service
• Gather and share learning from incidents to evaluate and improve the service
• Manage staffing levels to ensure the safety of women and babies

Julie Dawes, chief nurse at HHFT, said: “Safe and high-quality maternity care is a priority for us and as such this is a disappointing report to receive.

“Our maternity teams continue to work tirelessly to support the women in their care and we are working hard to implement the CQC’s recommendations.

“We appreciate the insights of the CQC in helping us improve the care we provide for women and babies. Our ongoing investment means that since the inspection, our staffing levels have improved following a sustained recruitment and training programme, and extra training has been put in place.

“This is a really useful report in supporting our vision of providing outstanding care to our patients and we are totally committed to resolving all of the issues raised.”

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