Jessop Wing

⚠ The average wait time for women being identified as requiring admission to labour ward to being admitted to the labour ward to commence induction was 1.47 days, however, we saw two occasions where women waited six days for their induction. This is not in line with national guidance.

⚠ Although investigating the backlog of serious incidents was a priority, they were not given additional time to conduct these. There were 25 incidents progressing in August 2022 which were anticipated to be in the final stages by the end of October 2022.

⚠ Managers were revising posters used to communicate learning as staff had fed back these were not the most effective method.

⚠ Midwifery staff were not fully compliant with all mandatory training, including safeguarding, Mental Capacity Act and Deprivation of Liberty Safeguards. Appraisal rates were 63% for clinical staff, 77% for medical staff and 63% for nursing and midwifery staff against a target of 90%.

⚠ Time-critical medications were not always prescribed or administered in a timely way. In the last audit of time critical medication completed in May 2022, 20% of critical medicines had not been prescribed and that 23% were not administered on time.

⚠ Audits of IPC procedures continued to be completed inconsistently and varied in meeting compliance targets across wards. Hand hygiene audits between January and August had only been consistently completed each month for the midwifery led labour ward and Rivelin ward. Hand hygiene audits were not completed consistently for Whirlow ward. …

⚠ Staff did not always respond to complaints within policy timeframes. We reviewed four complaints; two complainants had not received an outcome to their complaint for over nine months and one had received repeated extension dates.

⚠ The service did not currently have a regular audit schedule in place to ensure consistent oversight of the safety of the service.

⚠ The service’s risk register was not reflective of the current risks and areas of focus. The SLT were aware this was an area for improvement and that the current risk register was not an accurate reflection of the service. The risk register was a mix of corporate and directorate risk …

⚠ Timeliness of reviews and implementation of change was variable, which delayed improved outcomes for women. There was no evidence of following up of actions from previous meetings (PMRT meetings).

⚠ Although investigating the backlog of serious incidents was a priority, they were not given additional time to conduct these. There were 25 incidents progressing in August 2022 which were anticipated to be in the final stages by the end of October 2022. We reviewed NRLS between October 2021 and August …

⚠ The trust acknowledged that in the absence of an end-to-end maternity IT system they were unable to provide robust evidence for all elements of the Saving Babies Lives care bundle. The service did not currently have a regular audit schedule in place to ensure consistent oversight of the safety of …