Earlier inspection findings
pre-2024 framework ·
6 must-do
4 should-do
Must-do actions (6)
Legal requirements based on regulation breaches identified during inspection.
Must-do action 1 of 6
The service must ensure staff complete daily checks of emergency equipment.
Regulation: Regulation 12(1)(2)(a)(d)
⚠ However, daily checkswerenotalwayscompletedandsomeareasofclinicalwastewerenotproperlysecured. Staffdidnotalwayscompletedailysafetychecksofspecialistequipment.Wefoundaresuscitaireonthepostnatalwardhadbeencheckedon9outof12days(75%)inSeptember2023andthismaynotbeenoughtoprovideassurancethattheequipmentwassafeandreadyforuseinanemergency.Wefounddailysafetychecksofsomeemergencyequipmentwasmissingon9occasions(66%compliant)inthe4weeksprecedingtheinspection.Wefoundsignificantgapsindailycheckingrecordsonemergencyequipmentonthepostnatalward,onmilkandmedicinerefrigerators,andforambientroomtemperaturechecks.
Must-do action 2 of 6
The service must ensure infection prevention and control measures are effective and completed.
Regulation: Regulation 12(2)(h)
⚠ Staffdidnotalwaysuseequipmentandcontrolmeasurestoprotectwomenandbirthingpeople,themselves,andothersfrominfection.Theydidnotalwayskeepequipmentandthepremisesvisiblyclean,andwesawsomestaffwerenotin-linewithuniformpolicytominimiseriskofinfection. Staffdidnotalwaysfollowinfectioncontrolprinciplesincludingtheuseofpersonalprotectiveequipment. Duringtheinspectionweobservedseveralstaffmemberswerenotroutinelyusingglovesforpatientcontactwherethiswasappropriate,andthiswasaninfectionrisk.Intheatres,wesawstaffhadnotadheredtouniformpolicyandinfectionpreventionandcontrolmeasures.Weescalatedthistostaffandmanagersonthedayofinspection. Managerssometimesauditedtheenvironmentforinfectionpreventionandcontrolrisksandinthe6monthspriortotheinspectiontheservicewascompliantin11outof30instances(36%),non-compliantin5outof30instances(17%)andsubmittednodatain14instances(47%).Thismaynotbeenoughtoprovidemanagerswithassurancethattheenvironmentiskeptadequatelyclean.Auditsrecognisedthatbedspaceswerenotalwaysvisiblyfreeofdust,dirt,andbodilyfluidswhichwasarisk,andthisissuewasevidentonthedayofinspection. Maternityserviceareasweremostlycleanandhadsuitable,cleanfurnishings.Cleaningrecordswereup-to-dateanddemonstratedthatallareaswerecleanedregularly.However,wefoundisolatedareasofdust,litter,andstaining,whichweescalatedtostaffontheday.Equipmentappearedcleanhowever,itwasnotalwaysclearwhenitwasappropriatelycleanandreadyforuseas‘clean’stickerswerenotroutinelyused.ActionplanssubmittedbytheserviceshowedtheseissueswereidentifiedinJune2023andwerenotresolvedatthetimeoftheinspection.
Must-do action 3 of 6
The service must ensure medicines are stored, managed, prescribed and administered safely.
Regulation: Regulation 12(2)(g)
⚠ Theservicedidnotalwayssafelyprescribe,administer,recordandstoremedicines.Notallstaffcompletedmedicinesmanagementtraining. Wereviewed15setsofmedicinesrecordsonpaperandelectronicsystems,andtheseweremostlyaccurateanduptodate.However,staffdidnotdocumentpatientweightonmedicineschartswhichpresentsariskofprescribingandadministeringaninappropriatedoseofmedicine.SomepatientswhosemedicinesrecordswerereviewedhadbeenriskassessedforVTEandprescribedmedicine,andin1casewefoundahigh-riskweight-specificmedicinehadbeenadministeredwithoutadocumentedweightonthechart.Thiswasunsafepractice. Wesawevidenceofamedicinessafetyauditondeliverysuitethatwasdonethedaybeforetheinspectionandno concernswereidentified.Thiswasariskbecauseithadnotidentifiedconcernsfoundoninspectionthefollowingday,andthereforewaspotentiallyineffective. Staffdidnotalwaysstoreandmanagemedicinessafely.Theclinicalroomswherethemedicineswerestoredwerelockedandcouldonlybeaccessedbyauthorisedstaff.However,wefoundsomemedicineswereoutofdateand1drugroomwashotwhichcanimpactontheeffectivenessandshelflifeofmedicines.Weaskedtheservicetoprovideevidenceofwhathadbeendonetomanagethetemperatureinthisroomasstaffwereunsureifmitigationsweretaken,however,thiswasnotreceived.Theserviceprovidedacopyoftheirheatwavepolicy. Wefoundhardcopiesofout-of-dateguidelinesonemergencymedicines,whichpresentedariskthatstaffwouldgiveinappropriatecare.Weescalatedthistostaffonthedayforremoval.Wefoundsignificantgapsinthesafetychecksforseveralemergencymedicinesboxesthroughouttheunit.Theserviceused‘grabbags’forstafftouseinemergency situationsandsomeofthedocumentationofchecksonthesewasincompleteorabsent,thereforetheservicewasnotassuredthatmedicine‘grabbags’werereadyforuse.Intheatreswefoundsomemedicineswerestoredinunlockedcabinetsandwerenotroutinelycountersignedtoensureaccuratestockmanagementandsafeadministration,andthiswasnotriskassessed. Theserviceprovidedmedicinesmanagementtrainingbutdidnotmakesureeveryonecompletedit.Trainingrateswere54%ofmidwivesand57%ofdoctors.
Must-do action 4 of 6
The service must ensure action is taken to resolve identified shortfalls from audits with clear timescales for improvement.
Regulation: Regulation 17(2)(c)
⚠ Theleadershipteamhowever,didnotalwaysoverseetimelycompletionofrequiredactionstomakechangewhereriskswereidentified.Forexample:forinfectionpreventionandcontrol,equipmentpurchases,scanning,recordkeeping,andreadmissionrates. TheservicehaddevelopedanactionplaninresponsetoinfectionpreventionandcontrolissuesthatwereidentifiedinJune2023.Thedocumentshowedacomprehensiveawarenessofissuesfacingtheserviceandseveralareasofconcernhadbeenactionedandresolved.However,sometasksweremarkedascompleteonthedaybeforetheinspection,orhadnotbeencompletedoractionedbetweenJune2023andSeptember2023.DespitetheactionplanbeinginplacesinceJune2023,wedidfindinfectionpreventionandcontrolconcernsduringtheinspectionwhichmayindicatesomegovernanceprocessesrequiredstrengthening. Leadersdidnotalwaysimplementimprovementsinatimelywayoncetheyhadbeenidentified.
Must-do action 5 of 6
The service must ensure all documentation is completed in full, including but not limited to swab counts, fetal monitoring reviews, and MEOWS/NEWTT charts.
Regulation: Regulation 17(2)(c)
⚠ Staffdidnotalwayskeepdetailedrecordsofwomenandbirthingpeople’scareandtreatment.Recordswerespreadoverseveralelectronicandpapersystemswhichpresentedarisk.However,recordswerestoredsecurelyandavailabletoallstaffprovidingcare. Wereviewed10setsofrecordsandfoundtheywerenotalwaysclearandcomplete.Notesspreadoverseveralpaperandelectronicsystemscreatedopportunityforomission,inaccuracy,andinconsistency.Thishadbeenrecognisedbyserviceleadersandwasontheriskregister.Throughoutournotesreviewwefoundareaswheredocumentationhadnotbeencompletedaccordingtoprofessionalstandardsoraspertrustpolicy,includinglegiblenotesthatweresignedanddated,riskassessmentcompletion,carbonmonoxidemonitoring,theatrechecklists,fetalmonitoring,andswabcounts.ThiswasparticularlyconcerningastherewasanevereventofaretainedswabinFebruary2023. UnclearorincompletedocumentationwasathemeidentifiedwithinincidentswereviewedbetweenJanuary2023andJuly2023.Theservicehadaquarterlyrollingauditofrecordsinplacetomonitorthequalityofdocumentation.Therewasanauditofrecordsspecificallyinrelationtogestationaldiabetesinprogressatthetimeofinspection,andtheservicesuppliedrecord-keepingauditresultsfromJanuary2023toJuly2023.Datashowedtheareasofconcernidentifiedbyourrecordsreviewhadbeenpreviouslyidentifiedasongoingissuesattheservice,whichindicatedslowresponsetorisk.Therewasalargegroupofnon-compliantareasincludingbutnotlimitedtovenous-thromboembolism(VTE)riskassessment,routineantenatalinvestigationssuchasbloodpressure,fetalmovementsandurinalysis,andcorrectuseofMEOWScharts. Theservicenot always carried out. Staff sometimes used a nationally recognised tool to identify women and birthing people at risk of deterioration and escalated them appropriately. Staff used the Modified Early Obstetric Warning Score (MEOWS) however, there were several sets of paper documentation used by the service. This …
Must-do action 6 of 6
The service must ensure all junior doctors receive appropriate safeguarding training.
Regulation: Regulation 13(2)
⚠ Staffmostlyhadtrainingonhowtorecogniseandreportabuseandtheyknewhowtoapplyit.However,theservicedidnotmakesurealljuniordoctorshadappropriatesafeguardingtraining. Trainingrecordsshowedthat85%ofmidwives,76%ofobstetricconsultantsand57%ofjuniordoctorshadcompletedLevel3safeguardingtrainingforadultsandchildrenassetoutinthetrust'spolicy,andintheintercollegiateguidelines.Thetrusttargetcompliancewas90%.
Should-do actions (4)
Recommended improvements to enhance service quality.
Should-do action 1 of 4
The service should ensure that governance processes are strengthened, including but not limited to implementing improvements in practice in a timely way following safety concerns being identified, accurate monitoring of readmission rates, and timely review of guidelines and policies.
Should-do action 2 of 4
The service should ensure to minimise and mitigate the impact of short staffing.
Should-do action 3 of 4
The service should ensure incidents are categorised correctly by severity and harm-rating.
Should-do action 4 of 4
The service should consider implementing a second daily consultant ward round on delivery suite as per national recommendations.