Emerging themes from our national maternity inspection programme
Victoria Vallance, Director of Secondary and Specialist Care, provides an update on CQC’s ongoing national maternity inspection programme and offers early insight into the emerging themes, including good practice examples to support wider learning across all trusts.
I’d like to start this blog by thanking the maternity workforce for their dedication, skill and expert effort, working to provide compassionate care for families across the country day after day. It is a challenging time for the NHS and current pressures, which are heightened by the national midwifery shortage, mean services are operating with an increased level of risk.
We know that for many people, their experience of pregnancy and birth is a positive one. However, as we highlighted last July, multiple reviews and inquiries, including our own report on safety, equity and engagement in maternity services, have raised serious safety concerns. These concerns include people who use maternity services and their families not being listened to and staff not being supported to provide the care they want to deliver.
Our recently published 2022 maternity survey highlighted improvements in key areas including mental health support and hospital discharge delays. However, it also revealed that far too many women and birthing people feel their care could have been better. It was especially concerning to see that people’s experiences of care have deteriorated in the last 5 years, particularly in relation to accessing information and getting help when it was most needed.
For people accessing maternity services and for the workforce, our national maternity programme offers a real opportunity to support learning and improvement across maternity care nationally. Our targeted inspection programme has so far provided further evidence of the increasing pressures on frontline staff as they continue in their efforts to provide high-quality maternity care with the resources available. It has also shown us how some trusts are managing those pressures. Based on our first 20 trust inspections, we want to take this opportunity to showcase how some of the services are overcoming key challenges through good practice. In this first blog we are focusing on key challenges across triage, communication and personalised care, culture and training, and leadership.
By sharing these emerging themes, we urge trusts to learn from one another and improve their services as the programme progresses.
Triage
Providers need to focus on triage processes. Effective triage systems should enable staff to assess women and people who use services to ensure they receive the right care in a more timely and appropriate way. Factors that we have seen impacting on quality of delivery at 50% of trusts inspected so far include: patient prioritisation, timeliness to initial assessment, oversight of those waiting, staff training and competence.
However, we have also seen examples of services doing triage well, with RAG (red, amber, green) triage ratings being used to effectively prioritise patients based on clinical need and urgency. At one service, all staff received training in an evidence-based triage tool and had to show they had the right training and competencies to work in triage.
Communication and personalised care
Our 2022 maternity survey highlighted concerns around communication, with just 59% of women and birthing people saying they were always given the information and explanations they needed during their care in hospital. From our initial inspections, it was clear that issues with communication continue to impact care at some services, but we were encouraged to see some great examples of trusts making significant improvements in this area.
In these services, information has been made available in different formats to cater for a range of needs and empower people to make informed choices about their care. One trust used personalised care guidelines to keep staff focused on providing individualised care. Women and birthing people were offered genuine choice, informed by unbiased information.
Culture and training
Following our safety, equity and engagement in maternity services report, which highlighted the impact of poor working relationships between obstetric and midwifery teams, we were keen to look at staff culture as part of our inspection programme. While we continue to see variation between services, we were pleased to see examples of good multidisciplinary team working at many of the trusts inspected so far. It was clear that some organisations were working hard to support staff through induction and training. For example, one trust set up ‘pop-up’ training stations to support the upkeep of key skills such as perineal suturing, recognising that it may be difficult for staff to leave wards for formal style training days
It was also encouraging to hear staff at another trust report having an open culture, where concerns were listened to. Its staff survey found that 73% of staff felt able to make suggestions and the same percentage felt they had opportunities to show initiative. These figures align with national data from the 2021 NHS staff survey, in which 70.2% of respondents felt able to make suggestions and 72.3% reported having opportunities to show initiative.
Leadership and staffing
We have previously raised concerns about a lack of consistent leadership in maternity services. During our inspections so far, the quality of leadership we have seen has varied. However, we are encouraged to have found some examples of positive, approachable and supportive leadership. For example, at one service, leaders in maternity worked well with the rest of the trust, as well as external agencies and bodies to maximise the provision of care. Leaders completed daily walk rounds to ensure they were visible and could maintain a good understanding of clinical activity. Diversity and inclusion were prioritised across the service, with reverse mentoring in place and a programme to support staff from ethnic minority groups to become leaders.
It has also been reassuring to see several trusts demonstrate a culture focused on improvement, with learning following incidents, quality improvement projects, and innovative ways to support people who use services.
In a number of services, we saw examples of significant staffing issues, resulting in care delays and sometimes preventing one to one care during labour. We recognise the impact team dynamics have on safety and were keen to understand how teams work together to address these staffing issues. We found some examples of good practice where services had processes in place to manage staff levels safely. For example, one service consistently used policies on escalation and closure to keep senior managers and clinicians informed and involved during busy periods. This included having arrangements embedded to call on trained general nursing staff to support with care that was not midwifery-specific, such as providing post-surgical care.
Next steps
Hearing from people who use services is instrumental in shaping our understanding of maternity services and driving improvement. We are extremely grateful to everyone who has shared feedback on their experiences to feed into the current programme.
We will continue to listen to the voices of people who use services to inform our view of each maternity service inspected. And, in the coming months people who have a baby in January, February and March 2023 at an NHS acute hospital trust in England will be invited to take part in the next CQC national maternity survey. The survey asks people how they felt about the care they received while pregnant, during labour and postnatally. We hope that everyone receiving a survey this year decides to participate. Their feedback is crucial and will feed into what we know about the quality and safety of care and help trusts understand where they can take targeted action to improve.
We are committed to using what we learn from our national maternity programme to support frontline staff in their delivery of care, help accelerate improvements and facilitate wider learning across trusts. We will continue to share learning from the inspection programme as it progresses and hope to give more examples of practice having a positive impact on care in our next update.
