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9 June 2021

Sheffield Hospitals reassures women they will continue to receive safe, good care following CQC inspection of maternity services

Sheffield Teaching Hospitals’ Chief Nurse and Chief Executive have assured women coming to the Jessop Wing that they will continue to receive safe, good care following a decision by the Care Quality Commission (CQC) to lower the maternity service rating from Outstanding to Inadequate.

The change to the maternity service rating follows a two-day inspection by the CQC in March 2021.The inspection was only on maternity care and did not cover the Neonatal Unit, Gynaecology, or Jessops Fertility services.

The inspection covered three of the five CQC domains. Safe, Well Led and Effective. The other two domains of Responsive (rated as outstanding) and Caring (rated as good) were not reviewed at this inspection and remain unchanged. However new ratings were given for the other three domains which led to an overall drop in the service rating to Inadequate.

During the visit the CQC Inspectors found a number of areas of good practice within the maternity service and felt staff were focused on the needs of the women receiving care. Doctors, midwives and other healthcare professionals worked together as a team to benefit families. Medical staffing, including on site Consultant cover, was very good both in and out of hours. Infection control and cleanliness was also of a good standard and there is a culture where staff felt respected, valued and supported. They also commented that the service promoted equality and diversity in daily work.

However, following the inspection, the CQC also required the Trust to take immediate action to address some systems and processes which they considered were not robust enough around risk management, learning from incidents and triage and assessment. The Trust has responded with an action plan and many of the inspection recommendations have already been implemented. Inspectors also felt that midwifery staffing levels in some areas were lower than recommended by national guidance and had been impacted on by a number of vacancies. However, since the inspection 3 months ago, 30 new midwives have been offered posts and will be joining the Jessop Wing team in September. 14 Midwifery Support Workers have also been appointed and a further 11 are in training.

Kirsten Major, Chief Executive, Sheffield Teaching Hospitals NHS Foundation Trust said:
“I want to assure women coming into Jessop Wing to have their babies that our maternity teams work incredibly hard every day to ensure their care is always the number one priority and whilst we are exceptionally disappointed with the findings of the CQC report, we welcome the external scrutiny and have wasted no time in responding to the actions which have been identified as necessary. Many of the actions have been completed in the three months since the inspection took place. For example, our governance and risk processes are being reviewed including how we learn from incidents and respond to data collected nationally and locally. Elements of our assessment process needed further review which we have done and whilst our midwifery staffing levels have not declined, we are taking on board what the CQC has said and have already recruited 30 new midwives to ensure we continue to deliver the care women have come to expect from Jessop Wing. We clearly have some improvements to make but we are encouraged by the feedback from families who use the service which is very positive and reflects the commitment of our staff to provide good care and more often than not go above and beyond what is required of them.”

Professor Chris Morley, Chief Nurse, Sheffield Teaching Hospitals NHS Foundation Trust said: “Whilst there is a focus quite rightly on what we need to improve I am also pleased that the inspectors found several areas of good practice and most importantly they recognised that Jessop Wing colleagues were focused on the needs of the women receiving care and that doctors, midwives and other healthcare professionals were working together as a team to benefit families. Medical staffing, including on site Consultant cover, was considered very good both in and out of hours and infection control and cleanliness was also of a good standard. They also commented that there was a culture where staff felt respected, valued and supported and that staff knew how to safeguard women and their babies. The teams in Jessop Wing are responding to this report with the commitment and professionalism we see every day and are completely focussed on continuing to deliver safe, good care to women and their babies. If any women or their partners have concerns following this inspection, then please do not hesitate to contact us and the team will be happy to provide assurance.”

These are the urgent conditions the CQC have asked the Trust to meet and the Trust’s actions in response:

Ensure systems are put into place so that staffing is actively assessed, reviewed and escalated appropriately to prevent exposing women and babies to the risk of harm.

Trust response: Processes to match staffing levels to peaks in demand were already in place along with 24hr/7day a week escalation system prior to the inspection but they have been further reviewed and strengthened since the visit. Any member of staff can escalate a staffing issue so that it can be resolved, and the appropriate staffing level achieved. We have a bank of 40 plus registered midwives who work flexibly to cover times when additional staffing is required. Where there is a sudden peak in demand such as the instances the CQC were aware of, the escalation process was activated to ensure the women had the appropriate level of care and minimal delays to any treatment needed.

Ensure systems are put in place so staff are suitably qualified, skilled and competent to care for and meet the needs of women and babies.

Trust response: Face to face training had to be paused due to the pandemic but online training still took place. However, we are looking again at how we support staff with regard to training and development as the pandemic subsides.

Ensure effective risk and governance systems are implemented to support safe care. Ensure risk assessments and risk management plans are completed in accordance with national guidance and local trust policy and documented appropriate

Trust response: A complete review of the risk and governance systems is underway, and a number of changes have already been made including faster reporting of serious incidents.

Improve monitoring the effectiveness of care and treatment provided to patients.

Trust response: We have implemented a maternity dashboard detailing maternity outcomes and benchmarking these against National indicators. This dashboard is shared with staff in Jessop Wing, the Trust Board and regionally with the Local Maternity and Neonatal System to ensure scrutiny of the care provided at Jessop Wing. We have also put in place additional systems to ensure women are robustly risk assessed and prioritised on arrival at the Labour Ward Assessment Unit.

Correct processes are in place for investigating serious incidents that reduce delays and accuracy of investigations. Improve lessons learned and the sharing of lessons learned among the whole team and the wider service.

Trust response: We have overhauled the process for identifying and investigating incidents and we have invited the National Maternity Support Team into the Jessop Wing to provide additional guidance and support to help us identify areas where we need to make improvements or take forward positive developments that have already been adopted by other maternity units or services nationally. We have already made some improvements in relation to this, such as the implementation of learning forums where the multi-disciplinary team (MDT) come together to share and discuss incident action plans. We have also introduced the HSIB (Healthcare Safety and Investigation Branch) newsletter to update staff on themes from maternity services locally and nationally that have been identified.

Improve infection prevention and control.

Trust response: The inspection team found that staff used equipment and infection prevention and control measures to protect women, themselves and others from infection. They kept equipment and the premises visibly clean. However, a small number of cleaning records were not up to date at the time of the inspection, and some areas were not audited for cleanliness between 10 March 2020 and 17 August 2020 because audits were paused to reduce the number of staff entering areas unnecessarily as part of measures to limit the transmission of COVID-19. The Trust will continue to adhere to rigorous infection control and prevention measures and put in additional measures to rectify the full compliance of audits.

Ensure safe systems and processes to prescribe, administer, record and store medicines are in place and applied.

Trust response: The Inspectors found that staff used systems and processes to prescribe, administer and record medicines. However, some drug fridge temperature checks were not recorded when the inspection took place and other records were not completed as expected. All staff have been reminded of the importance of checks and record keeping.


For further information about this media release please contact Julie Phelan, Communications, Sheffield Teaching Hospitals NHS Foundation Trust on or 07507888647.

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