Review of Bedford Maternity Services April 2020

Undertake a cultural safety survey to establish the impact of the existing culture on safety within the Unit. I have found no evidence that safety is compromised but such a survey will provide a baseline on which to build change and is driven by shared values. The inclusion of all staff groups in this is essential.

The service and management teams should build on the work and feedback already commenced. I suggest that the team take stock of what has been done so far, distil key learning and messages from this and implement actions in a consistent and proportionate way.

Review the QIA completed as part of the introduction of Continuity Schemes and consider introducing some performance metrics that monitor impact on delivery of core service.

Medical leadership across the service should be reviewed to ensure consistency of expertise and input at divisional and service governance meeting.

Ensure that all action plans are up to date and that learning from incidents and complaints is fully embedded across the service.

Learning from exemplar sites, the introduction of a shared space for coffee/meal breaks used by all professional groups, including managers and consultants, has been shown to help create working relationships that are characterised by friendship and mutual trust. The service may want to consider this possibility.

Review and, where still applicable, implementation of the actions arising from previous reviews and inspections. Where actions are no longer applicable, be clear about why and share the decision making process with clinical teams using relevant messages.

Support the staff and management teams to develop their own culture together: how do they want to work, what questions should be asked to determine next steps, what is a proportional response to the event?

Think about promoting and sharing positive messages: there is much good about the Maternity Service as evidenced in the recent CQC maternity survey and indeed in the most recent CQC report. Celebrate the positive and change the narrative.