Your questions answered: Maternity Services
Your questions answered: Maternity Services
The Care Quality Commission (CQC) published its latest report and rating for the Countess of Chester NHS Foundation Trust on 15 June. The overall rating for the Trust remains as ‘requires’ improvement’. The CQC rated the Trust’s maternity services and its well-led domain as inadequate – a change from its 2018 ratings of good and requires improvement respectively.
In response, Chester Maternity Voices Partnership asked its service users what questions they would like to ask the Trust. The questions raised are listed below with answers provided by Natasha Macdonald, Director of Midwifery at the Countess of Chester Hospital NHS Foundation Trust.
If you have a question related to the publication of the Care Quality Commission’s report on 15 June 2022 that is not covered below you can send it to firstname.lastname@example.org and receive an answer. The answer will also be added to the list below on this webpage. All questions posted will be anonymised.
1. How have staff responded to the CQC report?
Staff at the Trust have been understandably disappointed – both in the overall rating as well as the ratings for our maternity services and well-led. But they were pleased to see that the rating for Caring was Good.
The maternity team have been particularly affected given our rating has changed but although staff have felt frustrated, they are a resilient and a tight-knit team who are determined to ensure we put the right solutions and measures in place to ensure the rating for maternity services will improve in the future.
Staff have been very concerned about the impact that the rating will have on service users currently using our services as well as those planning to do so in the future. They are aware that families may be feeling anxious and concerned and I want to assure those families that our staff are focused on providing the high quality and safe service that they and our local community expect.
The maternity team has already implemented improvements to address issues raised by the CQC and I’ve been impressed by their positive approach, how they have embraced the improvements required and their unwavering focus on their patients and the families using our services.
These measures will allow us to build on the Trust’s positive outcomes in maternity services noted by the CQC. This includes the consistently compassionate care provided by the Trust’s staff to patients, the reduced observed rate for perinatal mortality at the Trust (for September 2020 to March 2021) and our own data indicating that maternity services performed in line or better than the Northwest Coast average for neonatal deaths, still births and babies requiring cooling for the period between April 2021 and March 2022.
2. I want to know what improvements have already been made as they will have had an indication that the inspection didn’t go well before it was published? What changes have been implemented since the CQC assessed?
Prior to the CQC publishing its rating for the Trust, it issued the Trust with a warning notice relating to maternity services. The warning notice outlined a number of recommendations which we were able to act on immediately – before the report and formal announcement regarding the Trust’s ratings were announced.
We worked with other teams in the Trust, for example the governance and risk team to make improvements and we did this very quickly. We have also been working with the National Maternity Safety Support Programme which is an independent group of experts who have experience of supporting maternity teams to improve their services. Their expert advice, guidance and ideas have already helped us significantly to make the required changes to our service and identify opportunities for further work to enhance our service provision.
Some examples of changes we have made are:
- Improving our surgical management of post-partum bleeding by process mapping it and identifying issues and changes we could make to ensure there were no gaps.
- Rapid roll out of new incident management training to all staff. We focused on our maternity team first before opening this training up to the whole Trust.
- Implementation of the ‘all Wales pathway’ to risk assess against post-partum haemorrhage.
- New staffing model rolled out in maternity theatre.
- Implementing weekly incident review meetings for maternity services.
- Implementing a quality assurance audit to ensure the consistent assessment of risk in maternity services.
3. What is the Countess of Chester NHS Foundation Trust (COCH) prioritising from the CQC report?
Our priority is to our patients and service users and assuring them that the care we provide is high quality and safe. We don’t want anyone to worry or lose confidence in our ability to treat and care for them or their loved ones. Our plans to engage with the public to provide reassurance are in progress and of course, we want to continue to work with the MVP to support this work.
The CQC report along with the feedback they gave us during the inspections meant there were some measures which we could implement immediately following their visit – such as the incident and risk management training that we’ve rolled out to the maternity team very quickly followed by the whole workforce.
The Trust has also developed an action plan which clearly sets out the priorities and a clear plan to identify what needs to be achieved by what date.
4. What improvements are planned and when will families see the results?
The key change that families will see evidence of soon is the increase in capacity within the maternity team. The increase is in line with national recommendations from the national self-assessment tool. The new roles include increased provision within maternity governance and a dedicated audit midwife role. I hope to be able to update MVP service users on those new roles and the investment in the Countess’ maternity services in a future public MVP meeting.
We are planning to rebuild our Women’s and Children’s Building in the near future and we will be soon at a point where we will be inviting the MVP to work with us on the interior design.
5. What is the timescale to rectify the changes required?
The CQC have not specified time frames in which we must complete our actions however the recommendations included in the warning notice did have a deadline – mid May - and we implemented all the necessary changes by that date.
The Trust is working with our local maternity system (LMS), Cheshire Clinical Commissioning Group (CCG) and the national maternity team on further improvements.
Whilst we want to ensure we make these changes as quickly as we can, we are also very aware that we don’t want to take a rushed approach which might mean we don’t make the changes properly. Where we can and where it is appropriate, we have taken immediate action but for those actions where we need to take a longer-term approach, we are making sure we take a careful and thorough approach to ensure that the change can be embedded and be sustainable.
The CQC will visit the Trust again for an unannounced inspection, within three months and they will focus on the points in the warning notice to ensure that we have acted on improvements.
6. What role would you like the Maternity Voices Partnership (MVP) to have to support change and how will you go about supporting the MVP in that?
Maternity Voices Partnership is a key partner in supporting us to make the changes we need to and to help us engage with and support our service users and their families. The MVP acts as a vital source of information and feedback which we can use to further improve our services and ensure they reflect the needs of our local community. Looking ahead, we want to ensure we work with the MVP to co-produce materials that will help inform families that use our services and to help us ensure our services make the difference we hope they will to those families.
Our work with the MVP stretches beyond the CQC report of course. We also welcome and will benefit from their support following the publication of the Ockenden Report in March 2022. A key role will be for the MVP to help us ensure the information we produce for our service users is as good as it can be and that it meets their needs. Co-production is really important to me and the Maternity team and the MVP will enable us to do this in a truly meaningful and collaborative way.
7. I'd like to ask, which of the Ockenden recommendations do the team think will be the most positive for COCH?
The immediate and essential actions identified in the Ockenden Report all have exceptional merit and independent experts have recommended that they should all be implemented in all maternity services within the NHS.
We are continuing to focus on the actions we need to take and in a similar way to the CQC recommendations, we are looking at where we can make those changes quickly and which changes will take a longer time to embed. Embedding change in a sustainable way takes time but we remain committed and focused on ensuring all the actions identified in the Ockenden Report are made here in our maternity service.
The support from the MVP will be vital as we do this. With them as our audience, it is essential that we utilise the voice of our service users and continue to work closely with the MVP as they will help and support us to be the best service we can.
8. I know morale in midwifery is already fairly low because of staffing so I’m wondering what a report like this will have done to the morale and whether staff have had their own questions about practicalities?
I know that our staff – in maternity as well as across the Trust – were disappointed by the rating we received but the team are also aware that the report should be seen as an opportunity to learn and make changes in our practice which will lead to improvements. The report recognises the care that our staff provide but recognises the Trust needs to strengthen governance processes and reduce the risk of incidents in the future. The senior team including executive colleagues have met with teams to ensure this message has been made very clear to our staff and to support them in making and sustaining the improvements needed.
9. How will you ensure staff get the regular training they require rapidly when you are already struggling with a reduced workforce?
All staff are required to ensure they keep their training up to date and they are supported to do this by their managers. It can be challenging but maintaining training is a priority for the multidisciplinary team and our staff are very self-motivated to ensure they remain compliant.
We run training frequently, and for small numbers if required, to ensure we have good attendance and compliance. Our leadership team monitors compliance and staff can escalate any training related issues to them so we can work to resolve it. We are proud that even during the COVID-19 pandemic, our teams continued to ensure they remained compliant with all the necessary training.
Culture and leadership
10. My understanding from the report is that the failings are with the culture of leadership/management and not with any individual midwife or doctor. This concerns me even more – we know that people can only work in the systems they’re allowed to operate in, and people cannot work safely when they are being managed poorly with issues such as understaffing?
Although this question isn’t specifically about staffing levels I would like to cover this as I feel it is an important aspect of the service we provide and will give some assurances to our service users.
We have been working hard on our current staffing levels and I am pleased to say that although we had a number of vacancies, we have now successfully recruited to all of the vacant posts. Not all of the new recruits have started in their roles but in the coming weeks, they will join us. Staffing is an issue at a regional and national level so I am very pleased that we will soon have a full complement of staff. The recent appointments include two midwives from abroad and I hope that this is another way we can ensure we retain our current staffing levels.
We are working with the regional and national team to look for new ways to recruit into the profession as we need a model that is sustainable into the future – here as well as across the wider NHS.
In terms of the culture and leadership, my team and I are working very hard to improve culture, support for staff and the wellbeing offer we can provide. This work stretches across the Trust and had already begun in earnest before the CQC’s inspection. Our work is focusing on the NHS People Plan and Promise and with a new Director of People and Organisation Development having joined the Trust earlier this year, there is a significant focus on taking this forward.
There will be a much greater emphasis on wellbeing and the support that we offer to our staff. We now have a Health and Wellbeing Practitioner in post and she has been active in supporting individuals and teams, providing advice and guidance and ensuring they have access to additional support.
11. What are the leadership structures/management teams meaningfully going to do to shift the culture and improve working conditions for the midwives (and thereby improve care for patients)? I don’t want to hear about consultation/discussion, I want to hear about actual action that will make a difference day-to-day.
I agree with you that we need to take action that makes a difference to our staff and do so quickly. We are already working closely with our People and Organisation Development team to do this and I’ve outlined some of that work in the answer to question 10.
We have recently held our first ever Listening Week which included specific events scheduled for the maternity and paediatrics teams. They were able to meet with the chief executive and deputy chief executive to talk about issues that were concerning them, what it feels like to work here and what support they think will help.
Within those discussions there were some actions that would support staff and some that were very centred on our families. Some actions can be completed quickly while others will take much longer to complete.
As a Trust we will be providing regular updates to all staff on the issues they raised and what we have done to address them. We will hold more listening events to continue to actively engage our staff as we strive to improve. Within maternity services, our matrons and the senior team are very visible and accessible to staff and they offer support and guidance openly. In addition, we have regular safety champion walk arounds and a new executive buddy system where executive directors are paired up with clinical areas to ensure there is visibility and frequent contact and support to staff.
In 2021 the new national Continuity of Care model was introduced to maternity services. It has been a challenge to implement it at the Trust given the impact to staff working patterns. The feedback nationally reflects the Trust’s position, and the programme has been paused until there are further notifications nationally.
12. I think one of the most alarming statements in it was that in the latest NHS Staff Survey, staff morale scored the lowest nationally, so my question is what is being done to help boost staff morale/support staff wellbeing? There must be research out there that shows a correlation between happy staff and happy patients. Happy staff = retaining staff.
The National Staff Survey is sent to every member of Trust staff and the organisation is already taking positive action to improve morale.
Whilst the survey highlighted areas in which we need to improve, it also gave us some positive feedback and we will ensure that we build further on these areas.
We know that staff feel that they are trusted to do their work and that their work is valued by their immediate line manager. In maternity services, it was clear that staff felt we supported each other and that people were working well together to achieve goals. I am also pleased that right across the Trust people felt safe to speak up about concerns.
We have already taken some key actions to improve morale and wellbeing.
- We now have a dedicated Health and Wellbeing Practitioner who works with teams to give support and help them access resources and support available for a variety of issues.
- We have held and wellbeing day and are planning the next one as a way of promoting what we can offer staff and providing on the spot support to anyone who needs it.
- We are planning events related to specific issues such as menopause support – something that has been requested by staff.
In spite of the challenges of the last two years – with the Trust being one of the most severely affected in the country by the COVID-19 pandemic – we have managed to maintain high-quality care performance across a number of areas which is a testament to the hard work of colleagues.
Equality, diversity and inclusion
13. The Trust scored very poorly on equality and diversity. There's a particular mention for maternity of appropriate vitamin supplementation for black and minority ethnic groups. I'd like to know how they make assurances that the voices of black and minority ethnic groups are heard and what training staff receive to feel confident providing culturally sensitive care? Not just a tick box e-learning exercise that staff don't read and flick through (I'm allowed to say that as work for the NHS). Proper training that actually has meaning to staff.
Equality is a value that is exceptionally important to me as a leader. In a previous role, I developed an equity in maternity approach to ensure that outcomes were improved and I have been part of the national BAME sponsorship for colleagues. I have been in post at the Countess for three months now and I will be bringing my knowledge here to ensure we can make improvements and become a leading service in this area.
I am already working with our Audit Team to ensure we are meeting the recommendations regarding supplements. I know that the MVP are keen to ensure that there is equal representation and I encourage anyone with an interest in maternity services to get involved with the MVP to help inform our work.
We will work with our local maternity system and other providers to ensure that we procure and have access to the best training available.
Electronic patient record
14. The computer system has been a known problem for a long time. When will this be resolved?
Our Information Management and Technology (IM&T) team has been working tirelessly since the new electronic patient record system was launched last July. There have been challenges with its implementation but the IM&T team are progressing well with their plan to resolve all the issues. In the maternity team, we have had good support from the team in terms of dealing with the issues that specifically affect us and we have made good progress in improving our current system.
Whilst the new system has caused difficulties, the benefits it brings in the longer term are significant. We will be able to provide better, more responsive care to our families as we will have far superior technology at our finger-tips.
Other views on the current service provision
15. How does MVP feedback reflect the experiences of families using maternity services?
Chester MVP asks for feedback regularly and it is very useful to the Trust because it tells us how people feel about the care they have received, what their experiences have been like and where we need to make improvements. Feedback includes positive and negative comments and ideas and we can use these to inform our plans and our focus on improving patient experience. It also covers a range of areas including pain management and mental health.
Feedback collected by Chester MVP has reflected the findings of the CQC report and I’m focused on using not only the CQC report but also the MVP feedback to bring about swift changes to make a difference to our service users.
A recent example shared by our MVP from service user related to a national poster and the language used. I escalated the concern to the appropriate stakeholder group and the language was changed, supporting service users.
16. What are you doing to empower your women to have trust in their bodies and physiological birth?
This is really important to me. I want all those who use our maternity service to feel confident that they are receiving the advice and guidance they need to enable families to make informed decisions. Our birth options service is well evaluated meaning we can identify ways to make it better and more responsive based on the direct feedback from people who have used the service. We have a small midwife led birth centre and I’m keen we do more to promote this to our service users. Currently, we do not have a consultant midwife post, but this is certainly a role we could consider and I would welcome feedback from the MVP on whether they feel this would be a welcome addition to the team.
17. Has homebirth provision been, or will it be affected going forward? In what way?
I can confirm that homebirth provision is an integral part of the service we provide and there are no plans to remodel or remove the homebirth service. Having three birth options is exceptionally important. We protected this offer even during the height of the pandemic as we know how important it is to our service users. As a woman who had my babies at home, please rest assured that I will protect this offer.