Source · CQC inspection

Bridgwater Community Hospital

Provider Somerset NHS Foundation Trust Type NHS Healthcare Organisation Region South West

Overall rating: Not Yet Rated View full CQC report

Domain ratings

Five CQC key questions

Safe

Not Yet Rated

Effective

Not Yet Rated

Caring

Not Yet Rated

Responsive

Not Yet Rated

Well-led

Not Yet Rated

Earlier inspection findings

pre-2024 framework · 6 must-do 2 should-do

Must-do actions (6)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 6

Must do

Safe

The service must ensure where responsibility for the care and treatment of women and birthing people is transferred to timely sharing of information and care planning takes place.

Regulation: Regulation 12(2)(i)

⚠ Key information was not always shared effectively when care was handed over to other healthcare professionals, leading to an incident where a woman was transferred without a midwife or handover.

Must-do action 2 of 6

Must do

Safe

The service must ensure electrical equipment is properly maintained.

Regulation: Regulation 15(1)(e)

⚠ Electrical equipment was not properly maintained; several items were out of date for electrical safety testing, with compliance at 30.6%.

Must-do action 3 of 6

Must do

Well-led

The service must ensure there are effective processes for learning from incidents.

Regulation: Regulation 17(1)(2)(a)

⚠ Processes for learning from incidents were ineffective, and the birth centre lead was unaware of incidents in the past year.

Must-do action 4 of 6

Must do

Well-led

The service must ensure there are effective processes for amending the home birth and midwifery-led unit provision at times of increased demand on ambulance services to ensure timely transfer to the obstetric-led maternity unit is not delayed.

Regulation: Regulation 17(1)(2)(a)

⚠ Risks related to transferring women to the main hospital from the Mary Stanley Birth Centre were not effectively mitigated, as the service did not regularly review capacity and demand in the ambulance service.

Must-do action 5 of 6

Must do

Well-led

The service must ensure there are governance systems to consistently monitor the effectiveness of the service including local audits and processes to learn from incidents.

Regulation: Regulation 17(2)(a)(b)(e))

⚠ Leaders did not operate effective governance processes to ensure oversight of the birth centre, including poor oversight of activity levels, lack of formal audits for transfers, and failure to audit criteria for birth centre use or implement a program of regular local audits.

Must-do action 6 of 6

Must do

Well-led

The services should ensure all midwifery staff receive a yearly appraisal.

Regulation: Regulation 18(2)(a)

⚠ Not all community midwifery staff received a yearly appraisal, with a compliance rate of 58.6% against a trust target of 92%.

Should-do actions (2)

Recommended improvements to enhance service quality.

Should-do action 1 of 2

Should do

Well-led

The service should ensure clinical outcomes data in relation to the the Mary Stanley freestanding birth unit at Bridgwater Community Hospital is included in the maternity dashboard.

Should-do action 2 of 2

Should do

Safe

The service should ensure medicines are stored at the correct temperature.