Source · CQC inspection

Saint Mary's Hospital

Provider Manchester University NHS Foundation Trust Type NHS Healthcare Organisation Region North West Last inspected 28 Jul 2023

Overall rating: Requires Improvement View full CQC report

Domain ratings

Five CQC key questions

Safe

Inadequate

Effective

Not Yet Rated

Caring

Not Yet Rated

Responsive

Not Yet Rated

Well-led

Requires Improvement

Earlier inspection findings

pre-2024 framework · 8 must-do 3 should-do

Must-do actions (8)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 8

Must do

Safe

The trust must ensure they assess and do all that is reasonably practicable to mitigate risks to women, birthing people and newborns. Regulation 12(1)(2)(a)(b)

Regulation: Regulation 12(1)(2)(a)(b)

⚠ Staff did not always assess, monitor nor manage risks to women, birthing people and babies. Opportunities to prevent or minimise harm were missed as the service did not operate effective and timely triage processes. The service did not facilitate timely access to appropriate birth settings for women and birthing people.

Must-do action 2 of 8

Must do

Safe

The trust must ensure they deploy enough sufficiently skilled and experienced staff to appropriately assess and care for women and birthing people and mitigate risks in a timely manner. Regulation 18(1)

Regulation: Regulation 18(1)

⚠ The service did not always 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. Staffing levels did not always match the planned numbers putting the safety of women and birthing people and …

Must-do action 3 of 8

Must do

Safe

The service must ensure staff are up to date with maternity mandatory training modules. Regulation 12(1)(2)(c)

Regulation: Regulation 12(1)(2)(c)

⚠ The service did not make sure everyone completed mandatory training. Staff were not up-to-date with their mandatory training.

Must-do action 4 of 8

Must do

Safe

The service must ensure that staff complete safeguarding training appropriate to their roles. Regulation 12(1)(2)(c)

Regulation: Regulation 12(1)(2)(c)

⚠ Not all staff had training on how to recognise and report abuse. Not all staff received training specific for their role on how to recognise and report abuse.

Must-do action 5 of 8

Must do

Safe

The service must ensure staff adhere to infection prevention and control measures. Regulation 12(1)(2)(h)

Regulation: Regulation 12(1)(2)(h)

⚠ The service did not always control infection risk well. Staff did not consistently use equipment and control measures to protect women and birthing people, themselves and others from infection.

Must-do action 6 of 8

Must do

Safe

The service must ensure there are sufficient quantities of appropriate equipment, including fetal and maternal monitoring equipment, to ensure the safety of women, birthing people and babies. Regulation 12(1)(2)(f)

Regulation: Regulation 12(1)(2)(f)

⚠ Staff did not always have access to enough suitable equipment to keep women, birthing people and babies safe.

Must-do action 7 of 8

Must do

Safe

The service must ensure staff carry out effective monitoring of women, birthing people and babies during labour, including use of ‘fresh eyes’ and intermittent auscultation in line with guidance. Regulation 12(1)(2)(a)(b)

Regulation: Regulation 12(1)(2)(a)(b)

⚠ Staff did not always complete individual risk assessments to assess risk to women and birthing people. Fresheyes audits showed the trust target was not met in any month from October to December 2023; average compliance across the quarter was 78% and was worst in November 2023 at 73%. Staff compliance …

Must-do action 8 of 8

Must do

Well-led

The service must assess, monitor and improve the quality and safety of the services provided in a timely way. Regulation 17(2)(a)

Regulation: Regulation 17(2)(a)

⚠ Leaders did not always operate effective governance processes and action was not always taken to address risks in a timely way. Incidents were not always graded appropriately, and issues in triage and elective pathways had not been fully addressed at pace at the time of our inspection.

Should-do actions (3)

Recommended improvements to enhance service quality.

Should-do action 1 of 3

Should do

Well-led

The service should ensure that incidents are appropriately graded to ensure they can assess, monitor and improve the quality of services to women and birthing people.

Should-do action 2 of 3

Should do

Well-led

The service should continue to address issues and concerns using quality improvement initiatives and ensure they can evidence the impact of improvements made.

Should-do action 3 of 3

Should do

Well-led

The service should continue to complete audits in line with the audit plan and keep the plan updated.