william harvey hospital - cqc

This report describes our judgement of the quality of care at this location. It is based on a combination of what wefound when we inspected and a review of all information available to CQC including information given to us frompatients, the public and other organisations

Ratings

Are services safe? Requires improvement –––

Are services effective? Good –––

Are services caring? Good –––

Are services responsive? Good –––

Are services well-led? Requires improvement –––

Mental Health Act responsibilities and Mental Capacity Act and Deprivation of LibertySafeguardsWe include our assessment of the provider’s compliance with the Mental Capacity Act and, where relevant, MentalHealth Act in our overall inspection of the service.

We do not give a rating for Mental Capacity Act or Mental Health Act, however we do use our findings to determine theoverall rating for the service.

Further information about findings in relation to the Mental Capacity Act and Mental Health Act can be found later inthis report.

WilliamWilliam HarHarveveyy HospitHospitalalQuality Report

Kennington RoadWillesboroughAshford KentTN24 0LZTel: 01233 633331Website: www.ekhuft.nhs.uk

Date of inspection visit: 22 January to 5 February2020Date of publication: 28/05/2020

1 William Harvey Hospital Quality Report 28/05/2020

Overall summary

William Harvey Hospital is operated by East KentHospitals University NHS Foundation Trust. The trust has50 maternity beds across two sites. William HarveyHospital and the Queen Elizabeth The Queen MotherHospital in Margate, Kent. A total of 6,428 babies wereborn across the trust during the last year.

The trust is accountable to East Kent ClinicalCommissioning Group. Maternity services are provided toa large rural population with small pockets of severedeprivation and has a population that has increased by21,000 in 2019 due to multiple housing developmentsacross Kent. Since our last report in 2018 maternityservices have seen an increasing number of womenpresenting for pregnancy with complex health needs,who require higher levels of intervention.

The William Harvey maternity unit is run by the Womenand Childrens Care Group which provides maternityservices across a large area of East Kent. We inspectedmaternity services at William Harvey Hospital and theQueen Elizabeth the Queen Mother Hospital. This reportpresents our findings for our inspection of William HarveyHospital.

At the time of our inspection, the trust were reviewingmaternity and neonatal services after concerns wereraised by the Healthcare Safety Investigation Branch, NHSImprovement and the Care Quality Commission (CQC).This was due to a series of historic failures in the care ofwomen and their babies. The last CQC inspection wascarried out in August 2018 and rated maternity asrequires improvement overall.

Maternity services at William Harvey Hospital include 10consultant-led labour rooms and eight low risk labourrooms on the Singleton midwifery unit including tworooms with installed birthing pools. There are 28 beds onthe Folkestone maternity ward which provides care forantenatal and postnatal admissions. Other maternityservices include a fetal medicine unit, a twice weeklyconsultant led antenatal clinic, a two-bedded day careunit with to additional chair spaces, and a purpose-builtbereavement suite. Six community midwifery teams

operate across East Kent providing antenatal andpostnatal care and a homebirth service. William HarveyHospital is one of two hospitals in Kent to offer a level 3neonatal intensive care unit.

Antenatal satellite clinics are available at Kent andCanterbury Hospital in Canterbury, Buckland Hospital inDover and the Royal Victoria in Folkestone. We did notinspect these clinics as part of this inspection.

There were 3,796 babies born at William Harvey Hospitalduring the reporting period of January 2019 to January2020. The trust reported that 178 women opted to havetheir babies at home.

We inspected this service using our comprehensiveinspection methodology. We carried out theunannounced part of the inspection on 22 and 23January 2020, along with an announced visit to thehospital on the 4th and 5th February 2020.

To get to the heart of women’s’ experiences of care andtreatment, we ask the same five questions of all services:are they safe, effective, caring, responsive to people'sneeds and well-led? Where we have a legal duty to do sowe rate services’ performance against each key questionas outstanding, good, requires improvement orinadequate.

Throughout the inspection, we took account of whatpeople told us and how the provider understood andcomplied with the Mental Capacity Act 2005.

Services we rate

Our rating of this service stayed the same. We rated it asRequires improvement overall.

• The trust had not achieved compliance with all 10actions of their safety action plan during thereporting period and two actions remainedoutstanding.

• On maternity day care, standard operatingprocedures were not embedded. Risk assessingwomen was not robust and correct care pathways

Summary of findings


were not always identified quickly, to provide thenecessary care and treatment. We highlighted theseconcerns to the trust, and the care groupimplemented changes and informed staff.

• Maternity day care admissions and wait times hadnot been routinely monitored prior to our inspection,which meant staffing did not always meet the needsof the service.

• Leaders used systems to manage performance,however, these were not always effective in all areasof the service. Leaders had not always identified andescalated relevant risks or identified actions toreduce their impact.

• Safeguarding training rates for doctors did not meetthe trust target of 85%, only 75% of doctorscompleted it.

• The service did not always manage infection controlwell; we found urine specimens unattended inantenatal clinic and day care. Cleaning checks wereout of date on some equipment. The trust had tworecent cases of Meticillin-resistant Staphylococcusaureus during the reporting period.

• We had concerns about the placement of newbornresuscitaires. The Womens and Childrens care groupleads added this to the internal risk register as atolerated risk which will continue to be monitored.

• Staff in day care did not routinely report all incidents,which meant managers were not always aware of allavoidable events on the unit.

• The service did not always complete incident reviewsaccording to national time frames and theirmaternity transformation program.

• Antenatal patient records were not always clear, or inchronological order because 50% of records werestored digitally and 50% were hand written. Doctorsand midwives used different methods ofdocumentation in women’s patient care records.This had also been highlighted in a recent coroner’sreport.

• On-call consultant and medical cover for maternityand gynaecology was limited. The care groupleadership recognised the risk, and at the time of theinspection were taking steps to mitigate this.

• There were times when junior midwives workedalone in day care who did not have the necessaryexperience, knowledge and skills to escalatecomplex emergency situations. After our inspectionthe trust told us that they were reviewing rosters toensure there was always an experienced midwife onevery shift and staff could contact a senior midwiferyco-ordinator to escalate concerns.

• Antenatal early warning scores were not beingcalculated to see whether care and treatmentneeded to be escalated.

• Pregnant women accessed the waiting area via themain outpatients waiting area where people withlong term health conditions waited forappointments. This meant that they may be exposedto health conditions acquired by the non-pregnantpopulation.

• Maternity services did not provide a specialistwomen-centred, consultant-led perinatal mentalhealth service designed to provide continuity andtime for women with mental health conditionsin-line with national guidelines.

• The trust’s maternity statistics dashboard confirmedthe trusts postpartum haemorrhage rate was 5%which is higher than the current national average of2.7%.

• Midwives caring for women during routine caesareansection did not have sufficient time to supportmothers with skin to skin and infant feeding in thefirst hour after birth, which is vital to stabilise babies’blood sugars and temperature.

• Breastfeeding initiation rates were consistently lowand rarely met the national average of 82%.

However:

• The service had enough midwives to care for womenand keep them safe. Staff had training in key skills,and understood how to protect women and babiesfrom harm. Since our last inspection, the service hadmade improvements to make sure women receivedone-to-one care during childbirth

• The service had a vision for what it wanted toachieve and a strategy to turn it into action,developed with all relevant stakeholders. Since our

Summary of findings


last inspection leaders had worked to makeimprovements to its maternity service. Staffunderstood the service’s vision and values, and howto apply them in their work.

• All staff were committed to continually learning andimproving services. The service had a Faculty of MultiProfessional Learning, which delivered evidencebased safe training for all staff. Fetal monitoringtraining and care had improved in line with bestpractice.

• Since our last inspection, the trust had developed arobust system to measure, monitor and analysecommon causes of harm to women duringpregnancy and childbirth.

• Leaders were working to improve facilities andservices across maternity, the trust had invested innew equipment and drawn plans to transform theday care unit into a full maternity triage service.

• Doctors, nurses and other healthcare professionalsworked together as a team to benefit women. Theysupported each other to provide good care.

• Staff could give examples of how to protect womenfrom harassment and discrimination, including thosewith protected characteristics under the Equality Act.

• Staff shared key information to keep women safewhen handing over their care to others.

• Since our last inspection, the trust increased itspercentage of women receiving continuity of carer.

• During childbirth, staff completed risk assessmentsfor each woman on admission and updated themwhen necessary using recognised tools.

• The trust created a digital pregnancy MOMAapplication, where women could access healthpromotion advice.

• Staff followed systems and processes whenprescribing, administering, recording and storingmedicines.

• The service was inclusive and took account ofwomen’s individual needs and preferences. Staffmade reasonable adjustments to help womenaccess services. They coordinated care with otherservices and providers.

• Staff monitored the effectiveness of care andtreatment. They used the findings to makeimprovements and achieved good outcomes forwomen in most areas. Maternity staff reduced the3rd and 4th degree tear rate by 13% using bestpractice. The Singleton midwifery led unit providedexcellent care, with a low transfer rate to theobstetric unit. The unit’s neonatal death rate hadbeen reduced and was in line with the nationalaverage.

• Staff treated women with compassion and kindness,respected their privacy and dignity, and tookaccount of their individual needs. The unit’s friendsand family score for care overall reported that 97% ofwomen who responded to the survey were happywith their care.

• Most staff felt respected, supported and valued. Theywere focused on the needs of women receiving care.The service promoted equality and diversity in dailywork, and provided opportunities for careerdevelopment. The service had an open culturewhere women, their families and staff could raiseconcerns without fear.

• The service engaged well with staff, women and thecommunity to monitor, plan and manage services.

• Leaders had recently improved the governanceprocesses throughout the service with support frompartner organisations. However, the new governanceprocesses were not yet fully embedded.

Following this inspection, we told the provider that itmust take some actions to comply with the regulationsand that it should make other improvements, eventhough a regulation had not been breached, to help theservice improve. We also issued the provider with arequirement notice for breaches of regulation/s. Furtherdetails are at the end of the report.

Summary of findings


Contents

PageSummary of this inspectionBackground to William Harvey Hospital 6

Our inspection team 6

Information about William Harvey Hospital 6

The five questions we ask about services and what we found 8

Detailed findings from this inspectionOverview of ratings 13

Outstanding practice 45

Areas for improvement 45

Action we have told the provider to take 46

Summary of findings


Background to William Harvey Hospital

William Harvey Hospital is operated by East KentHospitals University NHS Foundation Trust. The hospitalopened in 1977 and is in Ashford, Kent. It is an acutehospital which serves the population of South-East Kent.Services include emergency and elective care; as well asmaternity, trauma, orthopaedic, paediatric and a level 3neonatal Intensive care unit. The site has been developedsince 1977 to accommodate the increasing population.

The hospital is situated at the gateway to Europe. Thearea has high levels of migration and increasedprevalence of common long term conditions. High levelsof social and economic deprivation are reported inThanet. Twenty-one percent of the population live in thebottom 10% of the most deprived nationally.

William Harvey Hospital is registered to provide thefollowing regulated activities:

• Diagnostic and screening procedures

• Family Planning

• Management of blood supply and blood derivedproducts

• Maternity and Midwifery services

• Surgical Procedures

• Termination of Pregnancy

• Treatment of disease and disorder

• Transport services, triage and medical adviceprovided remotely

Our inspection team

The team that inspected the maternity service at WilliamHarvey Hospital comprised a CQC lead inspector, a CQCInspection Manager, a specialist advisor with expertise inmaternity and a specialist advisor with expertise ingovernance.

The inspection team was overseen by CatherineCampbell, Head of Hospital Inspection.

Information about William Harvey Hospital

William Harvey Hospital has one acute maternity unit thatprovides all aspects of maternity care, and midwiferycare, family planning, termination of pregnancy andsurgical procedures.

The location has antenatal clinics, day care, deliverysuite, fetal medicine, with specialist clinics such asdiabetes, as well as a women’s ultrasound service. Acounselling room was available within antenatal daycare. The maternity unit had a consultant led deliverysuite where women with medical complications or whochose epidurals were cared for during childbirth.Folkstone ward was for women with high riskpregnancies, postnatal and transitional care for women

and their newborn babies. Transitional care was offeredto babies who require extra care or observations afterbirth, but do not require admission to the special carebaby unit.

The Singleton midwifery led unit offered low risk,straightforward childbirth for women who opted out ofhaving demobilising pain relief.

The service worked with the neonatal intensive care unit(NICU) which was adjacent to maternity services. NICU isa high-level special baby care unit, that provides care forbabies under 32 weeks or who weigh less than 1500grams, as well as critically ill newborns of any gestation.

Summaryofthisinspection

Summary of this inspection


We observed the ATAIN (avoiding term admissions inneonates) meeting on the level 3 Neonatal Intensive CareUnit.

There were six community midwifery teams across EastKent. They were based at children’s centres and GPpractices. We did not visit these services; however, wespoke with community midwives and the communitymatron by telephone. The service reported a 2.5%homebirth rate for the period from January 2019 toJanuary 2020.

We observed practice, spoke with seven women andthree relatives and we reviewed 15 patient records.

We spoke with 18 staff including doctors, midwives,health care assistants, reception staff, theatretechnicians, and senior managers.

The hospital has been inspected three times. The mostrecent inspection was in August 2018. We rated maternityservices as requires improvement.

Activity (From December 2018 to November 2019)

• 6,428 babies born cross-site

• 3,796 babies born at William Harvey Hospital

• 55.6% of babies were delivered normally

• 561 babies were born on the midwifery led unit

• 34.4% of babies were born by caesarean section

• 2.5% of babies were born at home

Track record on safety (January 2019 to January2020)

Trust wide for maternity

• Zero never events

• Two maternal deaths

• Seven neonatal deaths within 28 days of birth

• Zero incidents of hospital acquiredMethicillin-resistant staphylococcus aureus

• Zero incidents of hospital acquiredMethicillin-sensitive staphylococcus aureus

• Zero incidents of hospital acquired Clostridiumdifficile

Services accredited by a national body:

• UNICEF baby friendly infant feeding stage one

• Clinical Negligence Scheme for Trusts




The five questions we ask about services and what we found

We always ask the following five questions of services.

Are services safe?Our rating of safe stayed the same. We rated it as Requiresimprovement because:

• On day care, standard operating procedures were notembedded, risk assessing women was not robust and correctcare pathways were not always identified quickly, to providethe necessary care and treatment.

• Early warning scores were not being calculated on day care tosee whether care and treatment needed to be escalated.

• Only 75% had completed their safeguarding level 3 training.This was not in line with the trust’s target of 85%.

• The service did not always manage infection control well, wefound urine specimens unattended in antenatal clinic and daycare, and cleaning checks were out-of-date on someequipment.

• We had concerns about the placement of newbornresuscitaires. The Women and Childrens care group leadsadded this to the internal risk register as a tolerated risk, tocontinue to monitor.

• Doctors and midwives used different methods ofdocumentation in women’s patient care records. Antenatal carepathways were not always clear, up-to-date, or in chronologicalorder because 50% of records were stored digitally and 50%were hand written records.

• The service had limited out of hours on-call consultant andmedical provision for maternity and gynaecology. Thispresented a risk to women who required emergency medicalintervention. The service had recognised the risk and wastaking steps to mitigate this, including the use of regular safetyhuddles.

• There were times when junior midwives worked alone in daycare who did not have the necessary experience, knowledgeand skills to escalate complex emergency situations. After ourinspection, the trust told us they were reviewing rosters toensure there was always an experienced midwife on every shift.After our inspection, managers told us they had reviewedrosters and made sure junior midwives were supervised, andthat they could contact the band 7 maternity bleep holder toescalate concerns.

• Not all incident investigations were completed to national timeframes.

However:

Requires improvement –––




• The service had enough midwives to care for women and keepthem safe. Staff had training in key skills, and understood howto protect women from abuse.

• Over 95% of midwives had completed their mandatory training.• The service had a Faculty of Multi Professional Learning, which

delivered evidence based training for all staff.• The trust had invested in new training equipment that

simulated real life situations and staff attended annualupdates.

• New remote fetal monitoring equipment was being installedduring our inspection.

• During childbirth, staff assessed risks to women, and acted onthem.

• Based on national recommendations and learning from seriousincidents, the trust had implemented various safety measuresto reduce the risk to women and babies during childbirth.

• Since our last inspection, the trust increased its percentage ofwomen receiving continuity of carer.

Are services effective?Our rating of effective stayed the same. We rated it as Good:Because:

• The service provided care and treatment based on nationalguidance and evidence-based practice. Managers checked tomake sure staff followed guidance. Staff protected the rights ofwomen subject to the Mental Health Act 1983.

• Staff gave women enough food and drink to meet their needsand improve their health. They used special feeding andhydration techniques when necessary. The service madeadjustments for women’s religious, cultural and other needs.

• Staff assessed and monitored women regularly to see if theywere in pain, and gave pain relief in a timely way. Theysupported those unable to communicate using suitableassessment tools and gave additional pain relief to ease pain.

• The service made sure staff were competent for their roles.Managers appraised staff’s work performance and heldsupervision meetings with them to provide support anddevelopment.

• Doctors, nurses and other healthcare professionals workedtogether as a team to benefit women. They supported eachother to provide good care.

Good –––




• Staff worked well together for the benefit of women, advisedthem on how to lead healthier lives, supported them to makedecisions about their care and had access to good information.All women were routinely monitored antenatally as part of the‘saving lives’ care bundle.

• Staff monitored the effectiveness of care and treatment. Theyused the findings to make improvements and achieved goodoutcomes for women. Maternity staff reduced the 3rd and 4thdegree tear rate by 13% using best practice. The Singletonmidwifery led unit had good outcomes data for women havinga straightforward low risk birth in line with national guidanceand low transfer to the obstetric unit rate.

• Key services were available seven days a week.• The trust employed two fetal wellbeing midwives and created a

fresh ears and fresh eyes approach to interpretingcardiotachagraph readings.

However:

• The maternity statistics dashboard data confirmed the that thematernity unit’s post-partum haemorrhage rate was 5% whichis higher than the current national average of 2.7%.

Are services caring?Our rating of caring stayed the same. We rated it as Good because:

• Staff treated women with compassion and kindness, respectedtheir privacy and dignity, took account of their individual needs,and helped them understand their conditions.

• During childbirth women received one to one care from amidwife.

• Staff provided emotional support to women, families andcarers to minimise their distress. They understood women'spersonal, cultural and religious needs.

• Staff supported and involved women, families and carers tounderstand their condition and make decisions about theircare and treatment.

Good –––

Are services responsive?Our rating of responsive stayed the same. We rated it as Goodbecause:

• The service planned care to meet the needs of local people,took account of women’s individual needs, and made it easy forpeople to give feedback. Women could access obstetric care atseveral satellite clinics across east Kent.

Good –––




• The service was inclusive and took account of women’sindividual needs and preferences. Staff made reasonableadjustments to help women access services. They coordinatedcare with other services and providers.

• People could access the service when they needed it andgenerally did not have to wait too long for treatment.

• Kanga wraps were provided for women who chose tobreastfeed to help keep their baby close to them.

• It was easy for people to give feedback and raise concernsabout care received. The service treated concerns andcomplaints seriously, investigated them and shared lessonslearned with all staff. The service included women in theinvestigation of their complaint.

However:

• Maternity services did not provide a specialist women-centredconsultant led perinatal mental health service, to providecontinuity and time for women with mental health conditionsin-line with national guidelines.

• Managers did not keep accurate records of admissions or waittimes for pregnant women attending clinics and day care. Wehighlighted this and managers implemented changes andupdated staff.

Are services well-led?Our rating of well-led stayed the same. We rated it as Requiresimprovement because:

• Leaders had not always identified and escalated relevant risksor identified actions to reduce their impact. Leaders usedsystems to manage performance, however, these were notalways effective in all areas of the service.

• On maternity day care, standard operating procedures were notembedded. Risk assessing women was not robust and correctcare pathways were not always identified quickly, to providethe necessary care and treatment.

• Key patient outcome targets were not showing the targetedreduction in poor outcomes.

• The trust had not achieved compliance with all 10 actions oftheir safety action plan during the reporting period tworemained outstanding.

• Although governance processes had improved since our lastinspection with support from partner organisations, the newprocesses were not yet fully embedded.





• The trust failed to report 100% of serious incidents withinnational time frames, data confirmed reporting did not alwayscomply with national time frames.

However:

• The trust’s vision for the planning, design and safe delivery ofservices was founded in an inclusive multi-professional trainingand audit program, using the BESTT (birthing excellence:success through teamwork) framework for maternity services.

• Since our last inspection leaders had worked to makeimprovements to its maternity service. Staff understood theservice’s vision and values, and how to apply them in theirwork.

• Most staff felt respected, supported and valued. They werefocused on the needs of women receiving care. The servicepromoted equality and diversity in daily work, and providedopportunities for career development.

• The service engaged well with women and the community tomonitor plan and manage services.

• Staff at all levels were clear about their roles andaccountabilities and had regular opportunities to meet, discussand learn from the performance of the service.

• Leaders had plans to cope with unexpected events. Staffcontributed to decision-making to help avoid financialpressures compromising the quality of care.

• Staff were committed to continually learning and improvingservices. They had a good understanding of qualityimprovement methods and the skills to use them. Leadersencouraged innovation and participation in research.

• Research and innovation were encouraged and evidenceconfirmed that recently adopted models of staff training wereimproving outcomes for women and their babies. Staffcompleted evidence-based fetal monitoring training. All staffwere committed to the continued improvements anddevelopment of the Womens and Childrens care group.




Overview of ratings

Our ratings for this location are:

Safe Effective Caring Responsive Well-led Overall

Maternity Requiresimprovement Good Good Good Requires

improvementRequires

improvement

Overall Requiresimprovement Good Good Good Requires

improvement N/A

Detailed findings from this inspection


Safe Requires improvement –––

Effective Good –––

Caring Good –––

Responsive Good –––

Well-led Requires improvement –––

Are maternity services safe?


Our rating of safe stayed the same. We rated itas Requires improvement.

Mandatory training

The service supplied mandatory training in key skillsto all staff which kept people safe, and made sureeveryone completed it.

Midwives received and kept up-to-date with theirmandatory training. Data provided by the trust confirmedthat 95.6% of midwives were compliant. Cross-site 85% ofdoctors completed all aspects of mandatory training.

The provider had maintained their multidisciplinarylearning environment. Training was planned andorganised by the trusts Faculty of Multi ProfessionalLearning in Maternity. Courses covered all aspects ofobstetric and midwifery skills to support safe, emergencycare and treatment.

The trust employed a lead obstetric consultant andpractice development midwives to create, oversee androll-out midwifery education across both sites.

The faculty ensured that training was delivered in linewith the NHS England care bundle ‘Saving Babies Lives’2019. This focused on five key indicators to reduce pooroutcomes for mothers and babies. These includedsmoking cessation conversations in pregnancy, risk

assessments and surveillance for fetal growth restriction,raising awareness on reduced fetal movements, effectivefetal monitoring during childbirth and a mental healthcare pathway.

Staff received two full days of skills and updates inmaternity. This included modules on safeguarding atlevel 3. Multidisciplinary non-technical skills training (SIM)included human factors updates, risk, obstetric andanaesthetic emergencies. Anaesthetists, obstetric doctorsand midwives attended these sessions. Staff told usneonatal staff had not attended in the past, althoughthey were included in next year’s training schedule.

Staff completed mandatory neonatal life support trainingand 96% were compliant.

Adult and newborn life support were completed on aseparate training day. This was arranged by the facultyand 97% or midwives and 85% of doctors completed it.

Community midwives and paramedics completedcommunity SIM training within a community settingwhich focused on obstetric emergencies in a home orcommunity environment.

The trust used lessons learnt to update their mandatorytraining day for fetal monitoring. Cardiotachagraph (CTG)training was based on new physiological best practicefetal monitoring during childbirth. The fetal monitoringcompetency assessment framework was included in themandatory update. All staff received a full day trainingand this included CTG reviews. Records confirmed that ayearly competency test had been created for all staff toreinforce learning from this session and was due to berolled out this year.

Maternity

Maternity



Bi-annual training was provided to staff via e-learningmodules for perinatal mental health and bloodtransfusion.

Safeguarding

Staff understood how to protect women from abuseand the service worked well with other agencies todo so. Staff had training on how to recognise andreport abuse and they knew how to apply it.

Midwifery and support staff received safeguardingtraining specific for their role on how to recognise andreport abuse.

Midwives were trained to level 3 safeguarding in-line withthe Safeguarding Children and Young People: Roles andCompetencies for Healthcare Staff IntercollegiateDocument (2019). They routinely completed face to faceor online updates.

Training included, recognition and referral of femalegenital mutilation (FGM) and PREVENT training, which ispart of the governments counter terrorism strategy. Ithighlights vulnerable individuals at risk of radicalisation.

The trust set a target of 85% for completion ofsafeguarding training. Across both sites midwives were98.5% compliant within the reporting period. However,only 75% of doctors had completed their level 3 trainingduring the same period.

Staff knew who the safeguarding leads were and how tocontact them. They knew how to get advice and how tomake a safeguarding referral. Staff showed us how theycould access safeguarding referrals via their internal trustinternet system.

There were 1,900 safeguarding referrals made within theWomens and Childrens care group across all maternitysites during the reporting period and these were reviewedby the trust safeguarding leads.

Midwives and doctors knew how to protect women fromharassment and discrimination. This included womenwith protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of,or suffering, significant harm. They worked with otheragencies to protect them. Midwifery staff sent a

safeguarding referral to the local authority and concernswere also flagged on their electronic patient records. Thismeant all staff would be alerted so they could help tokeep them safe.

Maternity services followed the threshold criteria set outby the Kent Safeguarding Children Board. This meant apregnant child under the age of thirteen wouldautomatically be referred to the local authority. Thiswould be classed as an offence under the SexualOffences Act 2003. Young people that were already knownto the local authority were automatically referredincluding looked after children. Young people withconcealed pregnancies or FGM were also automaticallyreferred.

The trust did not employ a midwife lead for teenage orvulnerable women. Teenage pregnancies of 13-18 yearswere assessed on a case by case basis. This wasdependent on age, vulnerable indicators (for example,schooling), family support, age of partner and the stageat which they accessed maternity care.

The trust provided evidence of its involvement in seriouscase reviews and the learning actions from these. Thismeant the department was engaging with externalproviders and using the learning from these to improvethe way it protected vulnerable adults and children.

However, staff did not always have time to monitor visitorand patient activity on Folkestone ward. Visitors, mothersand babies were not always monitored when they arrivedonto the ward. We witnessed a visitor tailgate a motheronto the ward. Staff were providing care and had notcompleted any security checks when the visitor had usedthe buzzer to gain access. This meant the system was notrobust and not in line with the Royal College ofObstetricians and Gynaecologists 2008, Safer Childbirth:Minimum Standards for the Organisation and Delivery ofCare in Labour 2.2.26’ Security is an issue of importancefor staff, mothers and babies. A robust system must be inplace for auditing the protection of babies born inhospital.

The trust had a baby abduction policy. This containedclear flow charts to guide staff.

Cleanliness, infection control and hygiene

Maternity

Maternity



The service controlled infection risk well. Staff usedequipment and control measures to protect women,themselves and others from infection. They keptequipment and the premises visibly clean most ofthe time.

The service followed the trust’s infection control standardoperating procedure. This ensured women and babieswere protected from exposure to infection most of thetime. Ward areas were visibly clean and well-maintained.Standardised hand hygiene signs were displayed at theentrance of all ward areas. Hand decontamination gelwas accessible at the point of entry to each ward, andeach bedded bay on Folkestone ward and the deliverysuite.

Staff followed infection control principles including theuse of personal protective equipment when they hadclose contact with women and their babies. Latex freegloves and single use gowns were available in all clinicalareas. Staff wore sterile gloves and used sterileequipment for intimate patient contact.

The maternity unit completed weekly hand hygieneaudits in all areas. Data for the previous month confirmedthat staff were 100% compliant with handdecontamination guidelines.

In most areas furnishings were suitable for theenvironment. Equipment had been cleaned and wasmostly in good repair. However, some recliner chairs onthe delivery suite were old and in need of repair as theseats were ripped, this posed an infection risk. Staff toldus that the service were awaiting delivery of new reclinerchairs.

The delivery suite had been supplied with nationallystandardised infection reducing partition curtains in linewith the rest of the trust. However, these were not fittedon the Folkestone ward or in the day care unit. Managerstold us that they were awaiting replacement of thematerial curtains to the disposable ones in there nearfuture.

Staff cleaned equipment after patient contact andlabelled equipment to show when it was last cleanedmost of the time. Cleaning records were up-to-date inareas and proved that all areas were cleaned regularly.

We saw evidence that staff carried out daily cleaningchecks of specialist equipment. For example, weighingscales used to care for newborn babies had daily checkscarried out by midwives.

Delivery packs for women during childbirth were stored ina clean room, sealed, in date and were single use items.Labels displayed the creation and expiry dates ofequipment, areas we checked contained in date, safelystored un-broken packages.

Clinical waste was segregated in line with best practice.Bins were colour coded and sharps bins were clearlylabelled and accessible within all clinical areas. Withinthe sluice room on the delivery suite, staff used doublebagging to dispose of placentas. Placentas were stored ina chest freezer, which was routinely emptied.

Maternity staff completed daily fridge and freezermonitoring checks, for fridges that contained medication,breast and formula milks. Sterilising equipment wasavailable to all mothers, so they could clean and steriliseinfant feeding equipment.

Mothers and babies known to be at risk of carryinginfectious illnesses were admitted to side rooms. Staffused nationally recognised barrier nursing principleswhilst caring for women affected by infection.

Most consumable equipment on the delivery suite wassterile and single use, for example instrumental andchildbirth packs.

The theatre was deep cleaned after each use followinginfection control guidelines and using a theatre cleaningchecklist. Theatre staff cleaned and checked all theatreequipment. Staff wore sterile gowns and covered theirhair, and during surgery used face masks.

However, we found some midwives did not use thecorrect process for aseptic non-touch technique (ANTT)when preparing a woman for a sterile procedure intheatre. Staff we spoke with had basic knowledge of theANTT. The National Institute of Care and Excellence:Infection: Prevention and Control of healthcareassociate’s infection in primary and community care(2011) part 1.4. states that ANTT must be used for devicecatheter site care when accessing the system. Wehighlighted this to staff who told us that midwives wereshown this in practice during their preceptorshipprogramme, although this was not reviewed annually.

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Also, during our inspection of Folkestone ward we founda resuscitaire had not cleaned according to best practice.This was situated in the nursery area, it was dusty and the‘I am clean’ sticker was five days out of date. Wehighlighted this to ward staff who cleaned the resuscitairestraight away.

Also in the antenatal day care unit and the antenatalclinic, there were urine specimens in the toilet that wereawaiting testing. We raised this with staff, who told us thatdue to space issues, this was the only area women couldleave specimens and usually they were actioned at once.

The trust supplied data on infection control incidentswhich had occurred from January 2019 to December2019 cross-site. This data confirmed that there had beenof two incidents of hospital acquired Meticillin-resistantStaphylococcus aureus (MRSA) across both sites. The twocases of MRSA were confirmed across both sites duringroutine readmission swab procedures. These two caseswere in the early stages of investigation.

There were 56 reported incidents of Streptococcusagalactiae streptococcus (Group B strep) cross-siteduring the reporting period. Managers created a checkingand reporting process to make sure women could accesstreatment to avoid adverse outcomes for mothers andbabies exposed to this condition.

Environment and equipment

The design, maintenance and use of facilities,premises were tired and in need of upgrading due tothe age of the building. Although availableequipment kept people safe and staff were trainedto use them. Staff managed clinical waste well.

The facilities were not designed to meet the needs ofwomen or their families. The design of the building didnot follow national guidelines, because the hospital wasbuilt in 1977 and some areas were no longer fit forpurpose.

The trust completed annual health and safety checks ofthe care environment in all areas and we saw evidence ofthis. Maternity scored 100% for compliance to health andsafety standards in a recent review.

Staff on the day care unit completed routine equipmentchecks at the beginning of each shift and recorded this intheir cleaning log.

Midwives and health care assistants were taught to use allequipment throughout the unit, and this was checked bythe unit matron’s administrator.

Facilities for the twice weekly antenatal clinic were notsuitable for caring for pregnant women. For example, thearea was poorly signposted and lacked hand hygienesigns. Pregnant women accessed the waiting area via themain outpatients waiting area where people with longterm health conditions waited for appointments. Thismeant that may be exposed to health conditionsacquired by the non-pregnant population.

The clinical area was cramped, with limited space toassess women. Staff told us they routinely had to bringmaternity observation equipment with them tooutpatients. There was limited sink space to store andtest urine samples.

The resuscitation trolley was in a different area of theoutpatient’s unit and the inspection team noted that ittook four minutes to find this. The impact of this could bea delay in vital emergency resuscitation.

The maternity day care unit was small and cramped. Theunit provided a main treatment area which housed twochairs and two side rooms with treatment beds. Thetreatment area used to assess and treat women, was notprivate, and conversations could be overheard. Staff toldus that this area was used for women who neededcardiotachagraph (CTG) monitoring of their unbornbabies, and although there was a partition curtain thiswas not in use during our inspection, confidentialconversations could be overheard.

The lack of space on day care meant the service couldnot site a Resuscitaire on the day care unit. In the event ofa baby being born unexpectedly, midwives had to travelacross to the delivery suite to collect a neonatalresuscitaire. The walk was approximately 250 metresbetween two sets of doors from the day care unit to thedelivery suite, which could result in delays in neonatalresuscitation if required.

The delivery suite décor was tired and in need ofupgrading, women did not have access to en-suitebathrooms, bathing facilities were available across thehall from the delivery rooms. During childbirth womenwould have to leave their labour room to use the toilet, orbathe. Which had an impact on privacy and dignity andposed a risk of cross contamination of bodily fluids.

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Main theatres were well signposted and sited around thedelivery suite on the same floor. The neonatal intensivecare unit was on the same level as the delivery suite andaccessible via the maternity day care unit.

Birthing rooms were small and cramped on the deliverysuite. Neonatal resuscitaires’ could not be stored withinthe birth room. Four resuscitaires were available on thedelivery suite, with one sited near to the induction oflabour rooms, two at the top end of the delivery suite,one of which could be wheeled in one of the larger labourrooms when a planned pre-term birth was imminent.

Finally, one was sited opposite the high risk labour roomin the clinical room. This room contained the controlleddrugs cupboard, and obstetric emergency boxes forpostpartum haemorrhage, sepsis and eclampsia. Theresuscitaire was situated in one corner, there were nopiped oxygen or air facilities and staff had to rely uponroutine daily checks to make sure the cylinders were fulland could sustain a full resuscitation. In the case of a fullneonatal resuscitation staff may struggle with the limitedspace and difficult access to the gas cylinders.

Staff told us that medical gas cylinders were kept in adifferent area of the trust, when cylinders neededreplacing, porters had to bring the cylinders from anotherpart of the hospital. The impact of this may cause delaysduring complex resuscitation.

All staff we spoke with told us if potential risks wereidentified during early stages of labour the woman wouldeither be moved to the high dependency room or screenswould be placed around the open door of the room, andthe resuscitaire placed behind the screens. This gaveenough room for medical and midwifery teams within theroom and mother could see baby at all times.

However, if the risk was immediate and concerns werenot identified during early stages of labour the babywould be carried to the resuscitaire by the midwife. Thismeant the baby was moved away from mother withoutan identification tag and the mother was unable to see orbe with her baby during a potential life threatening andworrying time.

Senior leaders told us they recognised not having theresuscitaires within the rooms was not good practice andthere was a lack of privacy and sensitivity for mothers andfamilies. The Women’s and Childrens care groupmitigated the risk by completing a full risk assessment of

the site of the resuscitaire, which included real lifescenarios using a video camera. The risk assessmentrecognised the space limitations within the delivery suite,and confirmed that the equipment was situated in thebest place possible, although the matter was placed onthe trust risk register as a tolerated risk, which they wouldcontinue to monitor and review.

The trust invested in a trial of alternative smallerresuscitaire units and found they were not suitable forcomplex resuscitation. At the time of our inspection thetrust were reassessing the possibility of installing wallmounted resuscitaires and the manufacturer had beencontacted to complete an on-site assessment.

Staff told us that they risk-assessed babies due to be bornearly; mothers would be admitted to the largest labourroom, where a resuscitaire was set up, and the neonatalteam alerted of the imminent birth.

Twice daily checks were carried out on emergencyequipment on the delivery suite and the data stored onthe main desk within the unit. After reviewing the data wenoted that during January 2020, checks had been missedon five occasions. We raised this with the leadership teamwho investigated. The leadership response stated, “ourpolicy is that the resuscitaires must be checked twicedaily, as further assurance, this is now discussed at safetyhuddles”.

Clinical stock was stored safely and easily accessible tostaff in all areas of maternity. Staff told us that equipmentwas calibrated annually, and we saw evidence of this onthe equipment labels.

The midwifery led unit, was well designed, had enoughrooms to accommodate staff and women duringchildbirth. The area was clean, well signposted, and wellequipped with all emergency equipment and single usemedical supplies.

We did not inspect community equipment. However,community midwives told us they had access to all theportable equipment they needed to support women whochose to deliver their babies at home.

Assessing and responding to patient risk

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Staff did not always complete, or update riskassessments fully for each woman, and they did notalways take action to remove or minimise risks.Staff did not always identify or act quickly uponwomen at risk of deterioration.

During the reporting period the hospital did not have apurpose built maternity triage unit or provide 24-hourmaternity triage. This was not in line withrecommendations set out in The Royal College ofObstetricians and Gynaecologist (RCOG) report SaferChildbirth: Minimum Standards for the Organisation andDelivery of Care in Labour 2007. This guidance recognisedround the clock maternity triage can significantly reducethe burden of unnecessary admission to the deliverysuites with women presenting querying imminentchildbirth, or complications associated with pregnancy.

Due to a lack of space at William Harvey Hospital, it hadnot been possible to implement a dedicated 24-hourtriage unit and antenatal day care was the model usedduring the reporting period. The lack of triage createdgaps in risk assessments due to the absence of a clearguideline for caring for women with unplanned antenatalcomplications. The trust submitted a triage plan withinthe Clinical Negligence Scheme for Trusts action plan,approved by NHS resolution

Staff on the day care unit were not using the nationalsafety standardised modified early obstetric warning(MEOWS) score charts when pregnant women arrived atthe department with pregnancy complications orconcerns. This meant that high risk women were notalways prioritised for early review by doctors. However,staff on the delivery suite and midwifery led unit used thenationally recognised MEOWS to identify women at risk ofdeterioration and escalated them correctly.

Although, staff completed a basic risk assessment foreach woman on arrival which included a full set ofphysical observations completed by the maternity careassistant and clinical history taken by the midwife, whoalso completed a situation background assessment andrecommendation (SBAR) tool. Staff told us they woulduse their clinical judgement to risk assess and prioritisewomen for care. Staff on the delivery suite andmidwifery-led unit also used the SBAR tool. Theinspection team found that standard operatingprocedures were not embedded, risk assessing womenwas not robust and correct care pathways were not

always identified quickly, to provide the necessary careand treatment. During our inspection, staff were handeda copy of the triage standard operating procedure ratifiedfor the Queen Elizabeth the Queen Mother site. Thiscreated some confusion for staff working in day care as itwas not formally implemented for the William Harveysite. Newly qualified preceptor midwives sometimesworked alone in this high risk environment; the impact ofthis is that they do not have the necessary experience,knowledge and skills to escalate complex emergencysituations.

Women could call maternity day care unit between 8amand 8pm with any concerns regarding their pregnancyand staff would offer them an appointment usually onthe same day. However, we witnessed support staff takingcalls and giving women clinical advice, and not all callswere documented. So, the service did not have full insightof the impact these calls had on their clinical work.

We raised the risk issues in the day care unit with theleadership team, who provided a formal response, whichstated the following:-

• Staff were now recording and auditing the timewomen arrive on day care/triage.

• The trust had introduced a ‘red, amber green’ (RAG)rating system to assess order of priority for women tobe seen on attendance.

• Times of assessment and time seen by a clinician werecompleted on the maternity electronic informationsystem.

• Modified early obstetric warning score (MEOWS) chartshave been introduced. All women who attendmaternity triage have their MEOWS calculated. Thiswill be added to the SBAR form.

• The trust has introduced a flowchart to supportmidwives decision making, setting out the RAG ratingsand associated risk.

Other aspects of maternity care on the unit fulfillednational guidelines. Maternity booking appointments area nationally recognised risk assessment of womenpresenting for antenatal care, designed to make surewomen are placed on the correct care pathway in linewith the National Institute of Health and Care Excellence(NICE) Antenatal care for uncomplicated pregnanciesguidelines 2019. During womens first booking

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appointment staff thoroughly assessed women toidentify any pregnancy risks, and referred women whenrequired using an assessment tool which was containedwithin their digital patient records. Women highlighted as‘high’ risk would be referred to the obstetric teams withinthe trust and low risk women would continue theirantenatal care with community midwives. Data wereviewed confirmed that women were givenappointments in line with NICE 2019 Antenatal care foruncomplicated pregnancies guidelines.

Staff arranged psychosocial assessments and riskassessments for women thought to be at risk of self-harmor suicide when mental health complications wereidentified. Staff used the standardised Whooley 2depression diagnostic tool to identify women at risk ofdepression, in line with NICE Antenatal and postnatalmental health (2016) guidelines. Women who answeredyes to both questions were offered a patient healthquestionnaire self-reporting tool.

Women were given their handheld notes. These includeda printout of the risk assessment, advise on smoking,screening, alcohol use and fetal wellbeing.

Women were offered routine ultrasound screening, ataround 12 weeks, 20 weeks and 36 weeks to assess andplot fetal growth and wellbeing in line with NICE 2019Antenatal care guidelines. Carbon monoxide monitoringwas offered at booking, and throughout their pregnancyand this was documented in their maternity record.

Women identified as having diabetes, were invited toattend a consultant led diabetic antenatal clinic, wheretheir weight and blood glucose could be closelymonitored.

Women requiring extra appointments for antenatalcomplications were given appointments in the day careunit, where they would be assessed by a midwife andthen a doctor.

Women’s risk assessments were completed to supporttheir choice of hospital, home or midwifery-led unit birth.Women who requested a homebirth were risk assessedby the community midwives. Staff followed a strictexclusion criteria, which made sure women weremanaged effectively. If women were identified as highrisk, the risks were explained and documented. Womenwho chose a home birth against medical advice werereferred to obstetric clinics for a review and further risk

assessments. Records confirmed that women wereholistically assessed and given advice in line withnational guidelines. Women carrying twins haddoctor-led care throughout their pregnancies.

Mothers were assessed for venous thromboembolism(VTE) several times during their pregnancy and birth.Women identified as being high risk of having a bloodclot would be offered VTE prophylaxis medication in linewith NICE quality statement 9: Risk assessment – high riskof venous thromboembolism .

During childbirth delivery suite staff completed riskassessments for each woman on admission. Staff wespoke with understood the signs and symptoms of sepsisand how to implement the sepsis bundle care pathway toavoid delays in treating this life threatening condition.Sepsis grab bags were available for staff on the deliverysuite, although staff on day care did not have their ownstock.

The trust followed national guidance to continuouslymonitor babies heart rates during labour, whereindicated by a risk assessment. Women identified as highrisk had their babies heart rate monitored using a CTGmachine, this was attached to the mother’s abdomenduring labour. The trust had adopted and rolled out thenational physiological based CTG interpretation modeland improved its focus on intermittent fetal heart ratemonitoring since 2019.

Based on national recommendations and learning fromserious incidents, the trust had implemented varioussafety measures to ensure the safety of babies duringlabour. For example, a fresh eyes and fresh ears approachto CTG interpretation. ‘Fresh eyes’ CTG reviews werecarried out at regular intervals and concerns duringchildbirth were escalated to senior midwives and doctorswho would review women immediately. The CTG reviewerwould sign the CTG to make clear that a review had beenundertaken.

Maternity staff used a fetal wellbeing assessment toolduring labour. The tool was a sticker that was attached tothe CTG monitoring printout to highlight risks to all staffcaring for the woman during labour.

The trust invested in a central fetal monitoring system,which provided remote access to viewing fetal monitoringduring labour. During our visit, the new equipment wasbeing installed.

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Additionally, the trust had recruited two band 7 fetalwellbeing midwives. They would support midwives withCTG interpretation and audit outcomes to ensurecontinuous safety improvements were made based onnational guidelines.

Once babies were born, staff recorded ‘Apgar scores’,which measured the condition of the newborn infant, inline with national guidelines. This was to highlight anyrisks for all staff caring for babies in the postnatal period.

Members of the multi professional team collaborated todesign and implement a neonatal newborn assessmentpro-forma to document observations made at birth andthroughout the early postnatal period. The neonatalassessment tool was used in conjunction with a neonatalearly warning score (NEWS), to provide a thoroughnewborn assessment.

The newborn assessment tool rated babies using a trafficlight colour code system. Red was used for high riskbabies, amber for moderate and green for low risk babies.Babies scoring red or amber were provided withnationally recognised colour coded hats, so all staffthroughout the unit were aware of their currentcondition.

Staff on the delivery suite and Folkestone ward usedneonatal feeding charts, and a withdrawal observationchart to observe babies exposed to anti-depressionmedication, or illicit substances during pregnancy. Thedocumentation for newborn babies was designed tosupport health care professionals identify deteriorationsor improvements in the condition of the newborn baby.

Since our last inspection, the trust revised its escalationprocess for caring for women with increased risk toimprove the escalation of care in the event of anemergency. Maternity introduced daily safety huddleswhich were attended by all professionals working on theunit, including doctors, anaesthetists, paediatricians,midwives and nurses.

Huddles were performed in the morning, again at1.30pm. Out of hours (night time) safety huddles tookplace between 9.30pm and 10pm. On call consultantswould dial into the safety huddle and review patient care,capacity concerns and staffing on both sites.

The names of lead health care professionals including theon-call obstetric consultant registrar and neonatal on-call

consultants were displayed on a white board around thereception area. These were clearly visible to all staff andwomen so staff knew who to escalate to if a woman orbaby needed urgent medical review.

Midwifery staffing

The service had enough maternity staff with theright qualifications, skills, training and experienceto keep women safe and to provide the right careand treatment. Managers regularly reviewed andadjusted staffing levels and skill mix, and gave bankand agency staff a full induction.

The service had enough midwifery staff of relevant gradesto keep women safe. Data we reviewed demonstratedthat managers accurately calculated and reviewed thenumber and grade of midwives and healthcare assistantsneeded for each shift in accordance with Safer Childbirthnational guidance.

Information provided by the trust confirmed that themidwife to birth ratio was 1:28 this was an improvementon the last inspection which highlighted concernsbecause it was 1:30 in 2018. Although, staff reported anincrease of caring for women with complex health andemotional needs, which at times impacted on theirworkload.

In view of previous recommendations monthly auditswere carried out on midwifery care during labour. Dataprovided to us demonstrated that the trust provides over95% of women with one to one care during labour.

There was a systematic process in place to review staffingestablishment every six months. Staffing levels werebased on the number of babies born at the trust per year.

The unit employed one health roster administrator whowas responsible for creating duty rosters, in accordancewith the requirements of the unit. Staff were given plentyof notice of their planned rosters, which meant annualleave and study days could be planned.

There was a midwifery operational leader, who carried ableep to ensure they were accessible to all staff. They hadoversight of unit during daytime hours. The trustinformed us that they plan to extend the oversight toinclude out-of-hours cover with the recruitment of anadditional band 7 midwife.

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The operational lead had access to the rosters of eacharea, they would be able to redeploy staff to differentarea’s when required. For example, if delivery suite wasbusy, or in the event of staff sickness.

Antenatal day care was a busy environment and staffworked consistently to care for women. We reviewed theday care admission diary for the week commencing 24January 2020 and for the seven days, staff saw 256women. This averaged at 36.5 pregnant women per shift.On one day alone two midwives reviewed 43 women.Staff told us they were often called to help on the deliverysuite, which had an impact of the day care unit’s ownworkload.

Our last inspection highlighted concerns over the midwifeto women care ratio which was one midwife to 30 womenin 2018. The service had worked hard to recruit moremidwives and the ratio was now in line with nationaltargets with one midwife to 28 women. The maternitydashboard confirmed that 97% of women receivedone-to-one care during labour.

Shift patterns on the day care unit meant that only onemidwife worked on the unit until 10am and one midwifewas worked after 6pm until 8pm in the eveningsometimes these were junior midwives, although amaternity care assistant supported them. We highlightedthis to the trust and in their response they advised us thatthere would be a review of rosters to ensure that therewas always a band 6 or band 7 midwife workingalongside preceptor band 5 midwives.

An experienced midwife acted as a Supernummary shiftco-ordinator on the delivery suite and Folkestone ward inline with the Royal College of Obstetricians andGynaecologists (RCOG) Safer Childbirth guidance. Theco-ordinator would review staffing, the acuity of pregnantwomen and capacity levels throughout the shift, andwork with doctors and midwives to make sure they had acomplete overview on the service during their shift.

One band 7 midwife led the fetal medicine and day careunit. We noted that one whole time equivalent did notalways have a full oversight of both areas and reportedthis to the leadership team who informed us they hadbeen authorised to recruit another band 7 for the daycare unit.

Vacancy rates

The service had a low vacancy rate.

A vacancy rate is the percentage of reportedfull-time equivalent (FTE) staff in post againstplanned workforce levels.

Since our last report the trust had recruited moremidwives and staff retention was positive.

From January 2019 , the trust reported an overallmidwifery shortfall of 2.3%.

Bank and agency staff usage

The service used bank and agency nurses usedthroughout the maternity unit. Bank staff were used tocover sickness, training and annual leave.

The trust provided bank and agency staff usage data forqualified midwifery staff and unqualified midwifery staffin maternity, broken down between the two reportingunits of William Harvey Hospital and Queen Elizabeth TheQueen Mother Hospital.

From June 2019 to January 2020, the trust reported that8,571.22 of qualified midwife hours across William HarveyHospital’s maternity unit were filled by bank staff; whileagency staff filled 112.2 qualified midwife hours. Thesefigures equate to 4.4 annual full time midwifery roles.

During the reporting period January 2019 to January2020 the service had a sickness rate of 6.4% for doctorsand midwives (for the acute maternity department) and7.7% sickness rate on the midwifery led unit.

Medical staffing

The service did not always have enough medicalstaff with the right qualifications, skills, trainingand experience to keep women and babies safe fromavoidable harm and to provide the right care andtreatment. Managers regularly reviewed andadjusted staffing levels and skill mix, and gavelocum staff a full induction.

The Womens and Childrens care group reportedconsultant staff numbers at William Harvey Hospital as12.5 whole time equivalent.

The Healthcare Safety Investigation Branch and coroners’historic reports had raised concerns about the lack ofconsultant out-of-hours cover. In order to mitigate the riskof lack of cover on the unit, consultants extended their

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daily hours of working until 8.30pm. This change hadincreased resident delivery suite cover to 87.5 hours perweek and conformed to safer childbirth and RCOGguidelines, which recommend 40 hours delivery suitecover for trusts who have under 6,000 births per year. Inaddition, a business plan had been approved to recruitthree more consultants, and the advert had beenpublished nationally.

There were 16.4 middle grade doctors working at WilliamHarvey Hospital with a total of 33.8 across both sites. Thetrust reported funding and deanery issues around therecruitment of middle grade doctors, because fundingand deployment of trainee doctors was based on thenumber of births at the unit per year.

This current on-call system had put pressure on middlegrade doctors because one registrar covered maternityand gynaecology at the same time. Staff told us that theywere concerned about the risk of having to attendwomen attending the emergency department andmaternity unit emergencies at the same time. Theleadership team informed us that this risk was placed onthe trust risk register as a managed risk, because theteam were in the process of recruiting more doctors.

The trust had a planned elective caesarean section dailytheatre list which was organised in advance. Staff told usthat there was always a main theatres duty anaesthetistavailable on site who was available to cover emergencywork.

Junior doctors told us that they felt supported and thattheir seniors were very supportive at all times.Consultants were approachable and made it clear to staffthat they could be contacted for advice at any timeduring their working day.

The trust had reviewed its escalation process andimplemented processes to make sure patient safety wasat the centre of women’s care. Consultants created a draftstandard operating procedure of obstetric standards ofcare for the delivery suite (due to be approved during theinspection period), which would reinforce the escalationprocess. Staff told us they were always able to escalatetheir concerns. Safety huddles, on-call medics, and theplanned centralised fetal monitoring system wouldensure that escalation processes were strengthened.

Vacancy rates

From January 2019 to January 2020, the trust reported aconsultant vacancy rate of -0.1% and a medical doctorvacancy rate of 2.1% for maternity.

Bank and locum staff usage

The service had reduced rates of bank and locum staffused on the wards.

The trust provided the total number of hours worked byall medical staff in maternity at the trust for the last sixmonths of the reporting period. Therefore, it was notpossible to calculate the percentages of medical staffhours worked by bank and locum medical staff. Insteadonly the raw numbers are available.

From January 2019 to January 2020 , the trust reportedlocum medical staff hours used in Women’s andChildrens care group at William Harvey Hospital were 554hours filled by locum staff.

Records

Staff kept detailed records of women’s care andtreatment. Records were not always clear, orup-to-date, because some records were storeddigitally while others were paper records. Digitalrecords were easily available to all staff providingcare.

The Womens and Childrens care group used a mixture ofpaper and electronic medical records across all aspectsof care. Notes were not always contemporaneous, andtimelines and care plans were not always easy to accessor read. Women’s handheld records were not used by allhealthcare professionals involved in a woman’s care,which meant there wasn’t a cohesive, succinct and safeapproach to documentation.

A recent coroner’s report had highlighted that a mixtureof paper and digital care records posed a risk. Ourinspection noted gaps in what information was availableto whom and where they would access it from. Midwivesin the community setting did not always have access tothe internet. Two methods of documentation posed a riskduring an emergency because staff might not be able toaccess all the information they needed to inform clinicaldecision-making.

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Documentation within the digital system was clear, inchronological order and available to all staff who couldaccess a computer either within the unit or at one of thesatellite clinics in the community.

Access to the digital maternity records was passwordprotected and staff accessed information on a need toknow basis. The service was able to identify which staffhad accessed notes and when, which ensuredprocedures conformed to current general data protectionregulations.

We reviewed 15 sets of paper patient antenatal carerecords, out of these, 10 sets of records appeared to havegaps or missing entries from doctors who had reviewedwomen in the antenatal period. Five patient paperrecords did not contain a completed birth plan riskassessment. In addition, referral documentation was notclear in five sets of records, neither were doctor reviews.Staff told us that doctors preferred to input plans directlyonto the digital system. Midwives in day care also inputtheir observations and discussions directly onto thedigital patient record. Which meant that MEWS chartswere not being used and plotted in line with bestpractice. However, all 15 women’s handheld recordscontained clear documentation from their communitymidwife, which included, dates, signatures, clinicalobservations, blood screening results and conversationsduring pregnancy.

The trust informed us that they were currentlyredesigning women’s handheld notes, and moving overto a completely new digital system that they hope toroll-out in late 2020. The introduction of this systemwould allow women to view their maternity care in fulland will support safer record keeping in the future.

During labour women’s notes were hand written, staffmade brief contemporaneous entries of care at regularintervals. Maternity records contained SBAR and MEWSforms, which were clearly and regularly updated.Observations, blood results, and other importantinformation regarding care were also entered onto thedigital patient records. The digital system was robust andprovided health care professionals with a better oversightof antenatal care than the handheld records.

Staff told us main hospital notes were not alwaysavailable to them during a womans admission to thedelivery suite. This posed a risk, as the hospital notes

contained significant medical, social or psychologicalhistory that was needed to provide care. Women beingcared for during pregnancy at the Dover satellite clinicwould need their notes transported prior to childbirthand there were times when this did not happen.

Women and newborn babies were given a dischargesummary of their care during their stay before they leftthe unit. GPs and health visitors would be sent theinformation separately, so they could make any follow upappointments with women.

Records in all areas were stored securely. Paper recordswere kept in designated slots within the departmentaloffice areas.

Medicines

The service used systems and processes to safelyprescribe, administer, record and store medicines.

Medication was stored in a safe environment in all areas.Medicines cupboards for controlled drugs were keptlocked and the key was kept by the shift co-ordinator.Staff followed trust operating procedures for theprescribing and administration of medication within theunit.

All new midwives completed a medicines managementcompetency prior to their employment with the trust.However, staff were not expected to complete a yearlymedicines management competency to reduce the risk ofmedication errors.

Staff stored and managed medicines and prescribingdocuments in line with the provider’s policy. Controlleddrugs were stored separately to other medication andstaff access was by a key-coded lock and a key.Controlled drug logs were kept nearby, and containedpatient information and stock levels in line withregulations. Documentation we reviewed confirmedrecords were accurate and up to date.

Two staff members were required to dispense, check andadminister controlled drugs throughout the maternityunit in line with national legislation.

Medication was prescribed manually; the trust had notyet adopted an electronic prescribing system. Chartsclearly displayed patient information, including allergyinformation.

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On the ward we observed staff reviewing women'smedicines regularly and providing specific advice towomen about their medicines.

Staff followed current national practice to check womenhad the correct medicines.

The service had systems to ensure staff knew aboutsafety alerts and incidents so women received theirmedicines safely. The online digital incident reportingsystem was used to record these incidents, which wereaudited by the risk midwife.

Decision-making processes were in place to ensurepeople’s behaviour was not controlled by excessive andinappropriate use of medicines. Doctors made regularreviews of womens medication.

Incidents

The service managed safety incidents well most ofthe time. Most staff recognised and reportedincidents and near misses. Managers investigatedincidents and shared lessons learned with the wholeteam and the wider service. However, the service didnot always investigate incidents in a timely way.When things went wrong, staff apologised and gavewomen honest information and suitable support.Managers ensured that actions from patient safetyalerts were implemented and monitored.

Learning from incidents was a high priority for thematernity unit. Consultants and senior midwivesperformed root cause analysis and deep dives intopatient records. The trust had a cross-site investigationprocess in place for fresh eyes and questions from thefamily were included in the process.

A lead midwife was appointed to oversee the reportingand investigation of all risks cross-site. They wereresponsible for auditing data, reviewing policies, meetingkey performance targets, allocating investigations andfeeding back concerns to the leadership team.

Maternity services discharged their regulatory duty ofcandour. Families were now given the contact details of amember of staff who they can communicate with asrequired. The family also had involvement in the sign-offof the investigation reports, to make sure that the family’svoice was represented and that any questions heard, andresponded to within the investigation report.

Serious incident deep dive reviews were completed toidentify trends and learning. Reviews included the topicsof stillbirths, babies who had oxygen restrictions duringchildbirth and were sent for a treatment called coolingand neonatal deaths.

Most staff knew what incidents to report and how toreport them. Incidents were reported through the trust’sincident reporting digital software. However, some stafftold us that they did not report all incidents in day care.We were told of two women who gave birth alone withinthe bereavement suite which had not been reported onthe trust’s digital incident reporting system. We raised thiswith the leadership team who took immediate action toupdate staff at daily safety huddles and team meetings.

Staff told us they were not always aware of outcomes ofincidents or current audit data. Although, the trust hadcreated strategies to make sure staff received regularupdates and important news regarding updates andoutcomes. These strategies included, message of theweek, circulated to all staff and discussed at handover.Weekly delivery suite risk meetings were held, and allstaff were invited. This meeting was rotated betweeneach site. Meetings included presentations anddiscussions of recent reported incidents. Senior midwivesproduced a ‘risky business’ newsletter, which wasperiodically circulated to all staff and contained themesand learning points from serious incidents. Perinatalmeetings were held monthly cross-site and staff wereinvited to attend these.

The service did not always investigate incidents in atimely way in line with national standards. Evidenceprovided by the trust showed there were 141 maternityincidents of which 96 low to moderate harm incidentswere under review for more than 60 days at the time ofour inspection. The NHS Serious Incident frameworkpublished in 2015 requires trusts to investigate and reporton moderate harm incidents within 45 days. For seriousincidents, a period of 60 days was recommended.

Never Events

The service had no never events on the maternity unitduring the reporting period.

Never events are serious patient safety incidents thatshould not happen if healthcare providers follow national

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guidance on how to prevent them. Each never event typehas the potential to cause serious patient harm or deathbut neither need have happened for an incident to be anever event.

(Source: Strategic Executive Information System (STEIS))

Managers shared learning with their staff about neverevents that happened elsewhere.

Staff reported serious incidents clearly and in linewith trust policy.

In accordance with the Serious Incident Framework 2015,the trust reported seven serious incidents (SIs) inmaternity which met the reporting criteria set by NHSEngland from January 2019 to December 2019.

All serious incidents were reported to STEIS within 14days of occurrence.

The trust reported 1,687 incidents, the vast majority wereno to low harm, which is indicative of a healthy reportingculture.

Maternity services reported

• 2 maternal deaths

• 7 neonatal deaths within 28 days of birth

Safety Thermometer (or equivalent)

The service used monitoring results well to improvesafety. Staff collected safety information and sharedit with staff, women and visitors.

The service continually monitored safety performance byusing a maternity dashboard. The data collectedincluded, the amount of normal births, stillbirths,caesarean section rate and many other importantaspects of care. Staff used the maternity dashboard tomonitor and improve performance.

Are maternity services effective?

Good –––

Our rating of effective stayed the same. We rated it asGood.

Evidence-based care and treatment

The service provided care and treatment based onnational guidance and evidence-based practice.Managers checked to make sure staff followedguidance. Staff protected the rights of womensubject to the Mental Health Act 1983.

Staff caring for pregnant women followed standardoperating procedures which were aligned to nationalguidance. This included Royal College of Obstetriciansand Gynaecologist (RCOG) and The National Institute ofHealth and Care Excellence (NICE) 2008 & 2019 Antenatalcare for uncomplicated pregnancies, Safer Childbirth:Minimum Standards for the Organisation and Delivery ofCare in Labour 2007, and the Department of Health SaferMaternity Care: National Maternity Safety Strategy –Progress and Next Steps 2017.

Policies were available on the trust internal website. Filepathways were clear and easy to read. The policies weinspected were evidence based and had been reviewedwithin three years. Staff throughout maternity told ushow they could access policies cross-site and within thecommunity setting.

All women were treated equally, in line with the protectedcharacteristics under the Equality Act 2010. Womensneeds were thoroughly assessed. Pregnant women weregiven advice on maternity leave and benefits andmidwives signed their maternity certificate after the 20thweek of pregnancy in line with government guidelines.

Staff protected the rights of women subject to the MentalHealth Act 1983 and followed the code of practice. Thetrust had a clear referral pathway for women experiencingmoderate to severe mental health conditions. Womenwho needed further interventions were assessed atmultidisciplinary meetings, that included doctors,midwives and mental health care professionals.

GROW charts were used to plot fetal growth in line withthe Safer Childbirth minimum standards. Staff completedabdominal examinations at antenatal appointments andrecords confirmed this. All women were offered auniversal 36 week growth scan, which checked the healthof the placenta and the baby’s growth. Additionallywomen were given information on the importance of fetalmovements and the maternity notes containedinformation called ‘count the kicks’ to inform women onnormal fetal movements.

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The trust provided comprehensive guidelines for caringfor women during labour, which were in line with bestpractice. Mother and baby observation charts were basedon current national guidelines.

Women who required a caesarean section were cared forin the main hospital theatres. The inspection team notedthat staff did not offer enhanced recovery for women whohad just had their baby by caesarean, not all stafffollowed the correct process for aseptic non-touchtechnique. Midwives were task-focused and did not havetime to offer advice and support for the family as they hadto complete paperwork, assess the baby and prepare toaccept the next patient. The impact of this was thatmidwives did not have sufficient time to offer motherssupport with offering skin to skin contact at birth after acaesarean or breastfeeding support, which was reflectedin the units breastfeeding initiation rates. Both strategiesimprove adaptation to life outside the womb, stabilisingneonatal temperature and blood sugars.

At handover meetings, staff routinely referred to thepsychological and emotional needs of women, theirrelatives and carers. Staff handovers included the full unithuddle, and handover to individual midwives. At eachpoint of care midwives would make sure they handedover all details of the woman’s history using the SBAR(situation background assessment and recommendation)tool which included information on their emotionalneeds.

Nutrition and hydration

Staff gave women enough food and drink to meet theirneeds and improve their health. They used specialfeeding and hydration techniques when necessary. Theservice made adjustments for women’s religious, culturaland other needs.

Staff made sure women had enough to eat and drink,including those with specialist nutrition and hydrationneeds. Housekeepers would issue women on the wardmenus at the start of the day, which included a variety offoods including a vegetarian option. At meal timeshousekeeping staff would take meals to the women’sbedside.

During childbirth, and after a caesarean operation, stafffully and accurately completed women's fluid andnutrition charts, when required, using a standardisedfluid balance chart.

Specialist support from staff such as dieticians andspeech and language therapists was available for womenwho needed it. During the antenatal period, women witha body mass index greater than 35 were offered a referralto a dietician.

The ATAIN (avoiding term admissions into neonatal units)care bundle includes standard procedures to avoid newborn babies developing low blood sugars(hypoglycaemia). The trust had developed an infantfeeding policy, a neonatal guideline on glucose screeningand a hypoglycaemia policy. Policies were updated in thelast year and followed national guidelines.

Maternity services had been awarded stage one of theUnited Nations International Children's Emergency Fund(UNICEF) baby friendly initiative. The trust employed aninfant feeding co-ordinator who was responsible forimplementing all three stages of the baby friendlyinitiative. Their role included the promotion ofbreastfeeding, safe bottle feeding and training staff toteach and support new mothers with feeding. Babieswere risk assessed at birth, which meant some babiesneeded to have their feeding reviewed three hourly. Staffused an infant feeding chart to make sure new mothersknew when to feed their babies. Additionally babies wereweighed at birth, and day five, with babies weighingunder 2.5 kilograms weighed on day three.

Women choosing to breastfeed and who opted for skin toskin at birth had access to ‘kanga’ wraps, which werewrapped around mother and baby to help with newborntemperature control, bonding and lactation. The servicemade these available for women to buy, and the moneywas reinvested into the service.

Pain relief

Staff assessed and monitored women regularly tosee if they were in pain, and gave pain relief in atimely way. They supported those unable tocommunicate using suitable assessment tools andgave additional pain relief to ease pain.

Staff assessed women’s pain using a recognised tool andgave pain relief in line with individual needs and bestpractice. Women’s Modified Early Obstetric Warning Score(MEOWS) charts contained a pain assessment scoringtool, which was completed as part of the full MEOWSassessment.

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During childbirth, women requesting epidural pain reliefand would be assessed by an anaesthetist who wouldgain consent for the administration of the procedure andexplain the risks and benefits.

Staff prescribed, administered and recorded pain reliefaccurately. Staff completed ward rounds on the deliverysuite and Folkestone ward. Midwives prescribed mildpain relief medication under the standing orderprescribing procedure.

Women received pain relief soon after requesting it. Eacharea had its own medication storage area. Throughoutthe ward and day care, midwives had access to amedication trolley which meant women had access topain relief when they needed it.

Patient outcomes

Staff monitored the effectiveness of care andtreatment. They used the findings to makeimprovements and achieved good outcomes forwomen. The service had been accredited underrelevant clinical accreditation schemes.

Managers collected information about the outcomes ofpeoples care and treatments, this was routinelymonitored, and the findings were accessible to staff.Managers used information from the audits to improvecare and treatment most of the time.

The service participated in all relevant national clinicalaudits, which included MBRACE-UK (Mother and Babies:Reducing Risk through Audits and Confidential Enquiries).ATAIN and BESTT. Additionally, the unit submitted regulardata to Public Health England’s national antenatal andnewborn screening programs.

The NHS national screening program for pregnancy isdesigned to improve health outcomes for women andtheir babies. Maternity units are expected to comply withkey performance indicators (KPI) for several aspects ofcare; these include, blood testing, ultrasoundinvestigations and newborn bloodspot and infantphysical examinations. In line with national guidelinesthe trust gathered data on all the current screening KPI’s.

Ninety five percent of women attended their first datingultrasound scan by 13 weeks and 5 days, which was inline with National Institute for Health and Care andExcellence (NICE) Antenatal Care for UncomplicatedPregnancies clinical guidance 2019.

Women who were referred for follow up invasivescreening interventions was within the nationalguidelines at 89.5%. The data we reviewed confirmedthat reasonable efforts were made to contact all womenin the correct timeframe.

Routine scans identified 66 babies with developmentalabnormalities and women were offered counselling andadvice on decisions regarding the continuation of theirpregnancies.

Antenatal blood screening tests were offered to allwomen during their booking appointment. Dataconfirmed that just over 99.5% of all women were testedfor HIV, Hepatitis B, Syphilis, Sickle Cell andThalassaemia.

In accordance with the saving babies lives care bundle,the trust offered all women carbon monoxide screeningduring the antenatal period and just before they weredischarged from hospital after giving birth to their babies.

During their booking appointment, 93.7% of women hadtheir carbon monoxide levels checked, which was slightlyworse than the national target of 95%. Women whosmoked were offered a referral to a smoking cessationclinic. During the reporting period an average of 80% ofwomen were referred. However, only 10% of smokerschose to stop smoking during pregnancy.

The last National Maternity and Perinatal Audit ClinicalReport 2017 confirmed the national post-partumhaemorrhage (PPH) rate for a blood loss of over 1.5 litresto be 2.7%. The trust provided the units maternitystatistics dashboard report after the inspection, whichconfirmed that the trusts annual PPH rate for deliverysuite was 3.4% and for the midwifery led unit 1.6% whichequals a total of 5% during the reporting period which ishigher than the current national average. The unit’sdashboard reports post-partum haemorrhage of over2500 millilitres with a 0.6% annual rate.

The trust reviewed the incidence of obstetric analsphincter trauma and based on the findings hadintroduced training and new episcissors into practice to

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reduce the incidents of 3rd and 4th degree perineal tears.Since the introduction, there had been an annualreduction of 13%. Yearly statistics confirmed that the trustmet national yearly targets with an annual percentage of2.6%.

The units CTG assessments audits confirmed that 95% ofCTG assessments had a fresh eyes assessment. Out ofthese 87% were completed accurately.

Records confirmed that only 30% of women had anadmission CTG assessment this data identified a gap inlearning. Out of these 92% were completed accurately.

Initial assessments in labour to exclude chronic hypoxia(oxygen deprivation) were carried out on 100% of womenand 100% were completed accurately. The audit wasaccompanied by an action plan with recommendations.The action plan included the introduction of attaching anadmission assessment to the SBAR tool to make sure allstaff completed it, in line with the recommendations ofthe Saving Babies Lives report of 2016.

The MBRRACE UK: Mothers and Babies: Reducing Riskthrough Audit and Confidential Enquiries Across the UK2019 report confirmed the current national average ofmaternal deaths is one in 10,000. During the reportingperiod the unit reported two maternal deaths which wastwo out of 6,428.

During 2019 cross site, there were 24 babies bornunexpectedly outside of hospital grounds which was 1 toevery 2,000 births. This was better than the nationalaverage of four in every 1,000 births.

Women who chose to give birth on the midwifery led unit(MLU), were admitted using a strict admission criteria,which established a ‘low risk’ status for childbirth. Therewere 561 babies born on the unit during the reportingperiod. Records confirmed that the exclusion criteria waseffective as only 25 women moved from the MLU duringlabour. This equates to 4.6% of women who chose to usethe MLU.

The service was accredited by several schemes theseincluded the Clinical Negligence Scheme for Trusts(CNST) maternity incentive scheme at level 2, ATAIN(Avoiding Term Admissions into Neonatal Units) andUNICEF (United Nations International ChildrensEmergency Fund) baby friendly initiative ‘baby friendly’stage 1 accreditation in 2019.

However, maternity performance was not always in linewith national clinical targets. Maternity dashboard figuresconfirmed that the trust was not meeting the nationaltarget of booking 90% of women before their first scan at12 weeks and 5 days. The trusts performance averaged85% for most of the year.

The unit’s emergency caesarean section rates rangedbetween 19% and 22% during the reporting period. Thiswas higher than the national average of 16%. The serviceoffered second time mothers a VBAC (Vaginal Birth afterCaesarean) antenatal appointment to inform women’schoices for delivery of their second baby.

The care group did not meet national targets for referringwomen with a high body mass index of over 35 to anobstetric consultant clinic at booking. Data confirmedthat only 75% of women were referred within four weeksof their initial booking assessment.

The maternity dashboard confirmed that venousthromboembolism (VTE), assessments were completedfor 92.1% of women for the whole year which was slightlyworse than the 95% national target. The impact of thismeant some high risk women could miss time frames forbeing prescribed blood thinning medication.

Neonatal Outcomes and National Neonatal AuditProgram

The trusts neonatal audits were in-line with nationalstandards and data was collected and reviewed andaccessible to all staff.

In the 2019 national neonatal audit the trust’sperformance in the two measures relevant to maternityservices was as follows:

All mothers who delivered babies from 24 to 34 weeksgestation inclusive were offered a dose of antenatalsteroids. There were 185 eligible cases identified forinclusion. Of these, 85.1% of mothers were given acomplete or incomplete course of antenatal steroids. Thiswas within the expected range when compared to thenational aggregate, where 86.1% of mothers were givenat least one dose of antenatal steroids.

Mothers who delivered babies below 30 weeks gestationwere given magnesium sulphate in the 24 hours prior todelivery. The Prevention of Cerebral Palsy in PretermLabour (PReCePT) program is reducing the incidence ofcerebral palsy by offering magnesium sulphate to all

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eligible women in England during preterm labour (lessthan 30 weeks). The trust had created PReCePT leadswho made sure that women at risk of pre-term birth wereoffered magnesium sulphate. The hospital met theaudit’s recommended standard of 85% for this measure.

Neonatal admissions were reviewed at a weeklymultidisciplinary meeting, attended by the neonataldoctors and midwives. During the reporting period thepercentage of term babies admitted to the NICU unit was2.9%, which is better than the national average of 3.6%.

The government’s national term stillbirth rate target for2020 is set at 2.6%. The MBRRACE UK: Mothers andBabies: Reducing Risk through Audit and ConfidentialEnquiries Across the UK 2019 report confirmed a nationalaverage of 2.8 babies per 1,000 births during its lasttwo-year reporting period. The William Harvey Unit wasmeeting this target with figures for the reporting period of1.9%. The unit reported two neonatal deaths of babieswithin 28 days of birth.

Trust data for babies having skin to skin contact with theirmothers at birth was 72% across both sites. This did notmeet the current national average captured through NHSMaternity Statistics, England 2018-2019 which was 82%for the period. UNICEF baby friendly standard states:Support all mothers and babies to initiate a closerelationship and feeding soon after birth. This figure mayreflect the rate of women having caesarean sectionalthough staff told us that women were offered skin toskin in theatre.

There are various reasons for low breastfeeding initiationrates, which include, lack of conversations duringpregnancy, lack of antenatal breastfeeding education andwomen’s attitudes towards breastfeeding. Staff told usthat breastfeeding classes in the community werelimited.

During the reporting period 344 babies were re-admittedto the hospital within 28 days of birth. However, babiesadmitted under 10 days were admitted to the children’sward and not the postnatal ward. This meant the infantfeeding co-ordinator did not have an oversight ofreadmissions for weight loss and feeding complicationsin line with the UNICEF baby friendly guidance.

Competent staff

The service made sure staff were competent for theirroles. Managers appraised staff’s work performanceand held supervision meetings with them to providesupport and development.

Staff were experienced, qualified and had the right skillsand knowledge to meet the needs of women.

Managers gave all new staff a full induction tailored totheir role before they started work. Staff recordsconfirmed that all newly qualified midwives, completed afull induction, and a year as a preceptor. New staffattended the administration of medicine course onstarting at the trust and had to complete thecompetencies during their preceptorship. In the last year,all band 5 midwives had completed this competency.

The women’s care group provided a full induction forlocums and records confirmed this. Locum doctorscompleted a competency document prior to working oncall out-of-hours. The document included bleep holderdetails for all medical staff; details of shift handovertimes, emergency call numbers, access to guidelines andpolicies and information on the required mandatorytraining. Moreover, the document gave an overview ofimportant information. For example, the process foraccessing CTGs for women on oxytocic medication thathelps induce labour, the use of episcissors for childbirthand swab count procedures. Once the orientation wascompleted, the document was signed off by a consultantor senior registrar.

Further training was offered to staff on a once only basis,for example the UNICEF baby friendly initiative infantfeeding training was a full one off day, with a three yearlyupdate to be completed online. Staff also undertook oneoff e-learning for Venus Thromboembolism prevention inpractice and ATAIN e-learning modules.

Managers supported midwifery staff to develop throughregular, constructive clinical supervision of their work.The trust introduced TRiM (Trauma Risk Management) in2019. Some staff are TRiM practitioners and TRiMmanagers.

Managers made sure staff received any specialist trainingfor their role. Specialist midwife roles were created forvarious clinical conditions, these included, diabetes, fetalwellbeing, perinatal mental health and bereavementmidwives.

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Managers identified staff training needs during appraisalsand mandatory training, and gave them the time andopportunity to develop their skills and knowledge. Abirthing excellence: success through teamwork (BESTT)steering group was responsible for overseeing andprogressing the actions required for the achievement ofdeliverable teaching sessions that were aligned to theaction plan.

There were enough clinical educators to support stafflearning and development. The trust employed practicedevelopment midwives and a lead consultant foreducation, who were responsible for overseeing theeducation workstream aspect of the BESTT program.

Some midwives felt that they encountered barriers tocompleting mandatory practice assessor or newborn andinfant examination assessment training. Both skills arevital for career development and allow practice assessormidwives to support assessments of student and thelatter to support paediatric doctors with newbornexaminations.

Managers supported medical staff to develop throughregular, constructive clinical supervision of their work.Additionally, the trust promoted a national leadershipprograms for obstetric and midwifery staff.

Senior staff attended team meetings. Midwives anddoctors involved in cases were invited or had access tofull notes when they could not attend.

Managers identified poor staff performance viamonitoring, incident reporting and feedback. Any staffwho underperformed were promptly reviewed andmanagers supported staff to improve.

Appraisal rates

Maternity managers supported staff to developthrough yearly, constructive appraisals of theirwork.

Data provided by the trust confirmed that from January2019 to Jan 2020, 85% of all staff in maternity at the trustreceived an appraisal which met the trusts target.

Multidisciplinary working

Doctors, nurses and other healthcare professionalsworked together as a team to benefit women. Theysupported each other to provide good care.

Staff held regular and effective multidisciplinary meetingsto discuss women and improve their care. Ward roundswere attended by doctors, midwives and, whereapplicable, any specialists involved in care.

Staff worked across health care disciplines and with otheragencies, when required, to care for women. Doctors andmidwives worked with specialists across the hospitaltrust. These included physiotherapists, speech andlanguage therapists, neonatologists, paediatric nurses,safeguarding leads, and when necessary social services.Staff caring for women who were subject to care orderswould liaise with social care, mental health services andwhere applicable substance misuse leads. Staff involvedin complex cases would attend case conferences as partof the multidisciplinary process.

Staff referred women for mental health assessmentswhen they showed signs of mental ill health anddepression. Staff used a standardised assessment tooland there was a specialist perinatal mental healthmidwife who supported doctors and midwives caring forwomen with mental illness.

Seven-day services

Key services were available seven days a week tosupport timely care.

Midwifes, consultants and anaesthetists were availableon site. Consultants were available on site from 8am to8.30pm Monday to Sunday. Out of hours consultants wereon call from home and would attend the unit whenrequired. Obstetric doctors, midwives and anaesthetistsprovided 24 hours seven day a week cover for the deliverysuite, Singleton unit and the Folkestone ward.

Consultants led daily ward rounds on all wards, includingweekends. High risk women were reviewed byconsultants throughout the maternity unit. The unit didnot receive funding for 24 hour on-site consultant cover.To mitigate this risk, on call consultants dialled into a10pm huddle, with some consultants opting to sleep inthe staff accommodation if they felt the unit was underpressure, or there was a complex woman in labour on theunit.

Staff could call for support from doctors and otherdisciplines, including mental health services anddiagnostic tests, 24 hours a day, seven days a week.

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There were on-site pharmacy and pathology services thatwere available at all times of day and night. Maternityservices offered a 24-hour triage service. This servicecould be accessed at any stage of pregnancy.

Fetal anomaly screening was available Monday to Fridayfrom 8am to 8pm. Urgent ultrasounds examinations wereavailable on the day assessment units during these times.

Health promotion

Staff gave women practical support and advice tolead healthier lives.

The service had relevant information promoting healthylifestyles and support on every ward/unit. The trust haddevised a digital application for health promotion, thatwomen could download on to their smart phones.Information contained in the app related to commonpregnancy conditions, advice, support for smokers andinformation on fetal wellbeing.

Throughout maternity services, women could accesspatient information leaflets on various health conditions.Women who were diagnosed with conditions whichincluded, diabetes, group B Streptococcus, obstetriccholestasis and other pregnancy related conditions weregiven written information at their appointments.

Screening booklets were sent to women when theybooked for their antenatal care. The NHS screening leafletcontained information on screening pathology tests,ultrasound test and newborn screening for babies afterbirth.

Staff assessed women’s health when admitted andprovided support for any individual needs to live ahealthier lifestyle. During women’s stay on the ward, staffoffered carbon monoxide testing, infant feeding supportand advice on caring for their baby.

Additionally women had access to a digital pregnancyapplication created by the trust known as the MOMA appwhere they could access pregnancy health advice in-linewith national guidelines.

All aspects of maternity services were represented in thegovernance review meetings. Matrons and band 7midwives are invited to meetings and involved indecisions regarding the delivery of services.

Consent, Mental Capacity Act and Deprivation ofLiberty safeguards

Staff supported women to make informed decisionsabout their care and treatment. They followednational guidance to gain women's consent. Theyknew how to support women who lacked capacity tomake their own decisions or were experiencingmental ill health. They used agreed personalisedmeasures to limit women’s liberty in the event ofchronic mental illness.

Staff understood how and when to assess whether awoman had the capacity to make decisions about theircare. If midwives were unsure of a womans capacity tomake an informed decision, then they would liaise withthe doctors.

During our inspection, we witnessed staff gain consentfrom women for their care and treatment in line withlegislation and guidance.

When women could not give consent, medical staff madedecisions in their best interest, taking into account thehealth needs of the mother and baby, the impact on thewider family and their cultural beliefs and traditions.

Staff told us that women with learning difficulties wouldbe picked-up in community and a care package would beorganised by the community multidisciplinary team.Some midwives we spoke with appeared unsure of theprocess for gaining consent for invasive procedures suchas vaginal examinations, neither did they know where tofind the consent forms. Although staff did state theywould make sure a doctor was asked to review thesemothers.

Staff made sure women consented to treatment based onall the information available. For example, women whodeclined blood test screening were offered follow upappointments, further information and a doctor’s referral.Staff clearly recorded consent in the woman's records.

The trust dealt with mothers as young as 13. Staff madeadjustments to care and made sure extra support wasprovided. Staff used the Gillick Competence and FraserGuidelines to assess young women and make informeddecisions regarding their care.

Mental Capacity Act and Deprivation of LibertySafeguards training completion

Midwifery staff completed training on the MentalCapacity Act and Deprivation of Liberty Safeguards.

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Mental Capacity Act and Deprivation of Liberty Safeguardtraining is included in trust induction. From January 2020,midwives’ perinatal mental health awareness trainingwas included in the mandatory maternity update day.

Doctors completed dementia awareness training, whichcovered gaining consent, the Mental Capacity Act (2005)and Deprivation of Liberty Safeguards. Midwives wereresponsible for highlighting women with mental healthconcerns, during the booking risk assessment andthroughout the antenatal and postnatal period. Midwiveswould refer women experiencing mental ill health to theobstetric team or the duty psychiatrist for further careand treatment.

Women who had delivered their babies, but were subjectto the detention under the Mental Health Act 2005 wereisolated to side rooms, while undergoing case reviews.Once decisions were made regarding their care, staffwould find them a placement on a mother and baby unit,within the South East of England. Although, staff told usthat due to lack of facilities locally, there were times whenvery unwell mothers were sent to other parts of thecountry.

Are maternity services caring?

Good –––

Our rating of caring stayed the same. We rated it as Good.

Compassionate care

Staff treated women with compassion and kindness,respected their privacy and dignity, and tookaccount of their individual needs.

Staff were discreet and responsive when caring forwomen. Staff took time to interact with women and thoseclose to them in a respectful and considerate way.

Staff followed procedures to keep women’s care andtreatment confidential when possible. Women across theservice had risk assessments completed in private, exceptin the day care unit where space limitations meant somewomen may need to share a room with others. However,staff made sure that confidential information wasdiscussed in a private area.

The design of the bedded bays on Folkestone wardmeant that only partition curtains separated pregnantwomen and new mothers. Staff would discuss normalpatient care with women at the bedside, if motherswanted to speak in confidence, staff would take them to aprivate area.

Midwives and support workers we spoke with, wereadvocates for women. Staff had non-judgementalattitudes towards women and displayed understandingwhen talking about women with mental health concerns,substance misuse issues and learning disabilities.

During pregnancy women were allocated a communitymidwife who would provide continuity throughout thepregnancy for most of the time. During childbirth, womenreceived one-to-one care most of the time in line withnational guidelines. Women built trust with theirmidwives, which was vital for making informed decisionsregarding their care and treatment.

Women told us that staff treated them well and withkindness. Woman told us they were happy with their careand one woman we spoke with told us support staff hadspent a long time helping her to care for her baby after acaesarean section, despite the ward being busy.

Staff understood and respected the individual needs ofeach woman and showed understanding and anon-judgmental attitude when caring for or discussingwomen with mental health needs.

Midwives and doctors understood and respected thepersonal, cultural, social and religious needs of womenand how they may relate to care needs, and 96% ofmidwives had completed diversity training. Women couldrequest a female doctor for intimate procedures.Additionally, the trust provided a multi-faith chapel.Vulnerable women were referred to third party services.

We saw an example of a woman who had previouslyexperienced the loss of her baby during pregnancy beinggiven extra antenatal appointments to reassure herthroughout her pregnancy.

Emotional support

Staff provided emotional support to women,families and carers to minimise their distress. Theyunderstood women's personal, cultural andreligious needs.

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Staff gave women and those close to them help,emotional support and advice when they needed it.Midwives and support workers understood the impact forwomen who had difficult pregnancies and childbirth, andwellbeing was assessed throughout their care.

Since our last inspection, the trust increased itspercentage of women receiving continuity of carer.Women told us they saw the same midwife throughoutthe antenatal period within community clinics.

Midwives and support workers supported women whobecame distressed in an open environment, and helpedthem maintain their privacy and dignity in difficultcircumstances. Women who had been given bad newsregarding their babies’ wellbeing during an ultrasoundscan, were taken to a quiet area and comforted and giventime to accept distressing news. Staff supported womento make advanced and difficult decisions about theircare, and women and their families were given time toabsorb and assimilate bad news.

Women and families who lost their babies had time withtheir babies, because the trust had invested in cooledcots, and there were clear procedures to allow parents totake their babies home to grieve in private.

The trust employed two bereavement midwives whohelped parents with their loss and the funeralarrangements. Staff on the unit told us they completed ane-learning training module to help them deliver the bestcare for families who had experienced the loss of theirbaby.

Staff understood the emotional and social impact that aperson’s care, treatment or condition had on theirwellbeing and on those close to them. The service had apostnatal listening clinic for women who were affected bya traumatic birth.

Understanding and involvement of women andthose close to them

Staff supported and involved women, families andcarers to understand their condition and makedecisions about their care and treatment.

Throughout the maternity unit, we observed staffholistically assess women’s needs and preferences.Midwives and doctors shared evidence based advice, andwomen were true partners in their care.

Staff made sure women and those close to themunderstood their care and treatment.

Staff talked with women, families and carers in a way theycould understand, using communication aids wherenecessary.

Women and their families could give feedback on theservice and their treatment and staff supported them todo this. Patient feedback forms were available in all areasand when women were discharged they were given aform.

Staff supported women to make informed decisionsabout their care, during risk assessments, duringchildbirth and prior to discharge.

The feedback from the Friends and Family Test waspositive for all areas. Friends and Family test performancedata provided by the trust confirmed that 97% of womenwho responded to the test would recommend maternityservices to other pregnant women.

The trust performed similarly to other trusts for all 19questions in the CQC maternity survey of January 2020.During the summer of 2019, a questionnaire was sent toall women who gave birth in January and February 2019at smaller maternity units. The CQC received responsesfrom 160 patients at East Kent Hospitals University NHSFoundation Trust. We asked people to answer questionsabout different aspects of their care and treatment.Based on their responses, we gave each NHS trust a scoreout of 10 for each question (the higher the score thebetter). The trust scored 9 out of 10 for care during labour.However, women scored the service 6.2 out of 10 forhaving the opportunity to ask questions about their careduring labour. It is important to note these scores reflectcare across both sites and were similar to other trustsproviding maternity services.

Are maternity services responsive?

Good –––

Our rating of responsive stayed the same. We rated itas Good.

Service delivery to meet the needs of local people

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The service planned and provided care in a way thatmet the needs of local women and families and thecommunities served. It also worked with others inthe wider system and local organisations to plancare.

Managers planned and organised services, so they metthe needs of the local population most of the time. Spacelimitations due to the design of the building had acted asa barrier to further changes, although plans had beenmade to improve access and service delivery in the nearfuture.

The maternity unit had implemented severalworkstreams to make sure that women across the trustcould access care when they needed it. Consultantsidentified three themes for providing the best care,reduced variations in care, consistent language andformal leadership. This work contributed to the revisionof maternity care within East Kent Hospitals UniversityFoundation Trust.

Women had easy access to antenatal care, all womencould self-refer through an online webform on the trust’swebsite. A central booking office processed onlinereferrals and sent them to the appropriate midwiferyteam to arrange the booking. Women with complexhealth needs were booked early and referred forconsultant care at the relevant unit.

Delivery of antenatal care was in line with NationalInstitute of Health and Care Excellence (NICE) AntenatalCare: quality statement 2: continuity of care. This states,“pregnant women are cared for by a named midwifethroughout their pregnancy”. Women were booked in thecommunity by one of seven midwifery teams andremained with the same midwife, and a buddy midwifethroughout their care, unless their care plans changed.

Mothers were offered maternity care at children’s centresand doctors’ surgeries throughout East Kent. Womenliving outside the area could choose to book with theservice. Although, midwives completed their bookings atthe hospital these women did not receive the sameantenatal continuity of having the same midwife at eachappointment, as they attended the hospital for theirappointments.

Administrative staff monitored missed antenatalappointments and took action to minimise risk. Staffcontacted women who did not attend. If they did notrespond or failed to attend a follow-up appointment, staffliaised with the woman’s GP.

Maternity service managers employed specialistmidwives for perinatal mental health, diabetes, andbereavement. However, they did not provide a specialistservice for teenagers or vulnerable women.

The care group employed two perinatal mental healthspecialist midwives. However, at the time of ourinspection the maternity unit did not provide a dedicatedconsultant led perinatal mental health service for womenin need of additional mental health support, or specialistintervention. Staff told us this was not in-line with NHSEngland’s Perinatal Mental Health Care Pathways 2018recommendations. NICE Antenatal and Postnatal MentalHealth: Clinical Management and Service Guidance(2020). This states, “there should be a specialistmultidisciplinary perinatal service in each locality, whichprovides direct services, consultation and advice tomaternity services, other mental health services andcommunity services; in areas of high morbidity theseservices may be provided by separate specialist perinatalteams”. The trust advised that there were plans to recruita consultant with a special interest in perinatal mentalhealth. Records confirmed that 66 women were identifiedas having serious mental health problems at bookingduring the reporting period. The impact of this was thatwomen were referred to their GP for further assessment,or signposted to local community services, putting theonus on vulnerable women to manage their own mentalhealth needs whilst waiting for an appointment.

The delivery of peri-natal mental health services acrossthe trust meant women sometimes had insufficient timededicated to meeting their mental health needs at eachmaternity appointment. The perinatal mental healthmidwife did not have a caseload of women. Instead theywere there to offer to support and deliver teachingsessions to their midwifery colleagues. The impact of thiswas that community clinic midwives, would have toprovide care for all women for 20 minute appointments,which is limited time in which to discuss emotional carewith vulnerable women.

Staff could access emergency mental health support24-hours a day, seven days a week for women through

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the trust switchboard, who would contact the on-callpsychiatric team. However, staff told us that there weretimes when women had to wait for long periods before amember of the mental health team could review them.Also waiting times for attendance were not monitored, .

Community midwives followed-up women who hadsevere depression within the community setting withselective visits, and joint visits with mental healthprofessionals were encouraged.

The service worked closely with the local stakeholderssuch as the Maternity Voices group to improve care, sothat it would meet the needs of the local population.Maternity services looked at different ways of supportingparents. This included the introduction of longer clinictimes to make sure that women had time to talk aboutany their pregnancy concerns or discuss their birth plan.It also provided an opportunity for mothers and theirpartners to be signposted to therapeutic services likehypnotherapy for childbirth – a natural birthing processwhich helped women cope during childbirth had beenpiloted at the Queen Elizabeth The Queen MotherHospital. Once evaluated, there was a plan to provide thisservice at William Harvey Hospital.

Maternity services had worked in partnership with thelocal clinical commissioning group to create afrenulotomy clinic for newborn babies born with tonguetie, who were struggling to feed. This meant that womendid not have to travel to London as they had in the past.Mothers and babies were now referred, seen and treatedquickly to improve their ability to breastfeed.

The service had worked in partnership with externalservices to create antenatal education videos, whichwomen accessed via the trust’s maternity website. Theseincluded, during your pregnancy, your delivery, after thebirth and feeding your baby.

The delivery suite had recliner chairs so that partnerscould stay during childbirth. Partners were permitted tostay on the postnatal ward.

Meeting people’s individual needs

The service was comprehensive and took account ofwomen’s individual needs and preferences. Staffmade reasonable adjustments to help women accessservices. They coordinated care with other servicesand providers.

The service delivered care in line with NICE clinicalguideline 10 Pregnancy and complex social factors: amodel for service provision for pregnant women withcomplex social factors. The guidance makes the followingrecommendation “Service commissioners should makesure that trusts record the number of women presentingfor antenatal care with complex social factors”. Recordsconfirmed that the trust kept data for women presentingfor care with raised BMI, diabetes, complex mental healthissues, non-English speaking, substance misuse andyoung parents.

The trusts self-referral form for women asks questionsrelating to women’s ethnicity, first language, previousmedical and obstetric history.

Staff made sure women living with mental healthproblems, learning disabilities and dementia received thenecessary care to meet all of their needs. Women withcomplex needs had up to date care plans. Staff discussedcare choices with women and their families andcompleted regular reviews. Community midwives wouldcomplete maternity concerns forms which helped flagthese women for extra services. Social care referrals weremade in some instances to help women in need, andmidwives would liaise with childrens centres to offcommunity support groups.

NHS Englands national maternity transformationprogramme’s workstream 9 focuses on a range ofinitiatives to improve wellbeing, reduce risk and tackleinequalities from preconception to 6-8 weekspostpartum. East Kents areas of social deprivationcontribute to higher instances of obesity, smoking andpoor health. The trust employed a consultant midwife forpublic health. They did not follow women through theirpregnancy and birth but focused on tackling healthinequalities within the area, and overseeing nationalscreening programs.

Women who requested a caesarean because oftocophobia (anxiety about childbirth) were referred to adoctor for review.

Community midwives ran a monthly short antenatalclass. However, the trust did not provide infant feedingantenatal education within the community.

The service offered transitional care for term babies whoneeded to stay for observations or medication. Thismeant that babies with moderate medical problems

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could stay with their mothers on the ward, where theycould be cared for by midwives and visited by paediatricnursing staff for medication, instead of being admitted tothe neonatal intensive care unit.

The service was responsive to the needs of parentsfollowing baby loss. Parents who lost their babies, werecared for on the ‘twinkling stars’ bereavement suite. Theroom was designed as a ‘home from home’ environment.Families could grieve in private and were given time tocome to terms with their loss. One parent told us thatstaff had been compassionate and supportive and thatthey had been allowed to spend time with their baby.

The bereavement midwife would co-ordinate care forwomen who had lost their babies. The midwife wouldcomplete all the necessary documentation, organise timefor parents to spend with their babies, liaise withcolleagues and make sure that community teamsreceived updates regarding the family’s situation. Doctorsdebriefed parents following baby loss. Parents were giveninformation on burials and cremation services within thecommunity. Community midwives were notified andwomen who had experienced a loss could have theirpostnatal checks completed in the community.

NICE Antenatal and postnatal mental health: clinicalmanagement and service guidance (2020) State “healthcare providers should offer all women help and support ifthey need it”, to reduce the impact of trauma on women’slong term mental health. The service provided a ‘birthafter-thoughts’ clinic for women who had experienced atraumatic birth and wanted to debrief and review theircare records. A named band 7 and band 6 midwife ranthese clinics. Given the national imperatives for highquality maternity care, the consultant midwife role didnot follow anxious women through the care continuum tosupport positive outcomes following a previous trauma.

Policies were in place to support the care of womensuffering from mental illness after birth. Staff liaised withmental health colleagues so that women could bereviewed in line with NICE Antenatal and postnatalmental health guidance. Women experiencing chronicmental health issues would have to wait on the ward forthe trust psychiatrist to review them. The system wascomplex which meant that there were times when these

women would have to remain on the ward for up to aweek to await transfer to mother and baby units. Whennecessary extra carers were employed to monitor themuntil they could be transferred to a mother and baby unit.

The service met the communication needs of womenwho spoke different languages. During the reportingperiod, the trust cared for 235 non-English speakingwomen, who were offered an interpreter for their bookingin appointment. During routine appointments, midwivesused a telephone interpreting service to communicatewith women. Staff told us that in the event of anemergency the trust used a tannoy service to call uponbi-lingual colleagues to help with interpreting. Theservice did not provide leaflets in other languages;however, staff knew that NHS screening leaflets wereavailable in various languages, which they accessedonline.

Access and flow

People could access the service when they needed itand received the right care promptly. Waiting timesfrom referral to treatment and arrangements toadmit, treat and discharge women were in line withnational standards.

During the reporting period women attended day care3,958 times for planned appointments. Women, doctorsand community midwives could refer to the service andwere seen very quickly most of the time. The servicereceived 3,687 unplanned appointments for womenduring the reporting period. This equates to 21 womenper day who accessed day care during the reportingperiod. Staff told us that the impact on workload duringperiods of high demand was challenging because staffingrarely met the needs of the service. This happenedfrequently in the late afternoon and early evening.

The service provided satellite obstetric antenatal clinicsacross east Kent, which reduced travelling times forpregnant women. Obstetric clinics were available inDover, and Canterbury which offered emergency scansand fetal monitoring. Women could access the clinics forplanned appointments or unplanned attendances if theyhad developed health concerns. Records showed that8,182 women were seen at these satellite clinics duringthe reporting period.

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When women were discharged from the unit, they weregiven the contact details of the hospital and communitymidwifery teams in the event of complications. Maternalreadmission data provided by the trust showed that 195women were readmitted within 48-hours of childbirth,this equates to 5.1%.

Managers and staff worked to make sure that they starteddischarge planning as early as possible. Although parentshad to wait for the neonatal doctors to completenewborn and infant physical examinations. There wereseveral midwives on the unit trained to complete babyexaminations and if the unit was very busy staff would beallocated to support the paediatric doctors and checklow risk babies. On the ward, one midwife had completedtheir prescriber training and another was waiting forconfirmation on their professional registration. Thismeant that midwives could prescribe medication whendoctors were unavailable, and this helped to speed-upthe discharge process.

Staff planned women's discharge carefully, particularlyfor those with complex mental health and social careneeds. Doctors and midwives would assess women fordischarge home from the ward. The dischargedocumentation was completed by a band 3 dischargeco-ordinator on the authority of the healthcareprofessional. Women were given a discharge notification,postnatal care leaflets and contact telephone numbers.

Concerns were flagged to the shift co-ordinator andstaffing was reviewed when the unit was busy. The unithad to divert women in labour three times during thereporting period to its neighbouring site.

Staff supported women and babies when they werereferred or transferred between services. Women wouldreceive a discharge notification that listed their care andmedication during their stay. Community midwiferyteams would be informed of the discharge and womenwere visited the following day after discharge home withtheir baby. Notifications were sent to the GP and thehealth visiting teams, any baby needing a paediatricfollow-up would have appointments sent to their parents.

Before our inspection, managers in day care had notmonitored wait times for routine or emergencyappointments. The impact of this was that women maynot have received urgent treatment within agreed

timeframes and national targets. When we highlightedthis to managers, they implemented changes to theadmission diary to reflect arrival and wait and seen timesin line with national guidelines.

Although managers had not previously monitored waittimes, they took steps to try to make sure that women didnot stay longer than they needed to. For example, on daycare, one midwife had completed their sonographertraining, so that they could assist with ultrasound scans..

Inductions were planned and women were admitted toan area of the delivery suite and monitored throughouttheir stay.

Learning from complaints and concerns

It was easy for people to give feedback and raiseconcerns about care received. The service treatedconcerns and complaints seriously, investigatedthem and shared lessons learned with all staff. Theservice included women in the investigation of theircomplaint.

Women, relatives and carers knew how to complain orraise concerns. There was a clear process and patientinformation leaflets were available in all areas, withinformation including contact details.

Staff understood the policy on complaints and knew howto handle them. Managers investigated complaints andidentified themes and shared the outcomes with staff vianewsletters and feedback. Matrons would triagecomplaints and allocate them to the relevant band 7 shiftlead for investigation and a response. The matron wouldreview the response and create a written response within28 days of receiving the complaint which was in-line withthe trusts complaints guidelines.

Ward staff had listened to women’s feedback about noiselevels on the ward during the night. The unit had investedin earplugs for women and these were provided onrequest, to help women sleep.

Are maternity services well-led?


Our rating of this well-led stayed the same. We rated itas Requires improvement.

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For this core service inspection our assessment of wellled is an assessment of the leadership, governance andmanagement within the Womens and Childrens caregroup. However, we did interview the trust’s medicaldirector and chief nurse during this inspection."

Leadership

Leaders had the skills and abilities to run theservice. They understood and managed thepriorities and issues the service faced. They werevisible and approachable in the service for womenand staff. They supported staff to develop their skillsand take on more senior roles. However matrons didnot always have sufficient time to driveimprovements due to their large portfolio ofresponsibilities.

The service was led by a triumvirate structure consistingof a clinical director, head of midwifery and operationsdirector. The triumvirate engaged and communicatedwith staff and worked well together. A new obstetricsspeciality clinical lead and new site leads at eachmaternity unit strengthened clinical leadership across thesites delivering services, together with a senior midwiferystructure introduced by the head of midwifery after theirappointment in 2018.

A senior consultant who was educated and experiencedin transforming healthcare worked 50% of the time inclinical practice and 50% in a lead education role. Theyled on improving and supporting delivery of training aspart of the trust’s BESTT (birthing excellence: successthrough teamwork) programme. Staff across the caregroup spoke highly of the work they had done to improvetraining.

The head of midwifery was the driving force behindchange. The triumvirate reported to the chief ofoperations. The chief nurse did not have responsibility forthe delivery of the maternity transformation program.The head of midwifery was professionally accountable tothe chief nurse and they had regular one to one meetings.

The chief nurse was the trust board maternity championand had confidence in the head of midwifery and themultidisciplinary team to deliver the improvementagenda. The Womens and Childrens clinical director, andhead of midwifery were local safety champions. They met

bi-monthly. The chief nurse attended quarterly meetingswith the Health and Safety Investigation Branch (HSIB),was responsible for final responses to complaints andevery month reviewed the friends and family test.

The deputy head of midwifery was responsible foroverseeing staffing, safety and effectiveness at WilliamHarvey Hospital. The unit employed two matrons, one forthe oversight of services within the unit and one foroverseeing community midwifery services. Both wereaccountable to the leadership team for working practiceswithin their area. Matrons were responsible for updatingstaff on changes to practice, compliance, incident reviewsand auditing services to meet national and internaltargets.

Some senior staff did not always have sufficient time orresources to drive the transformation program and otherimprovements. The unit matron represented numerousservices from fetal medicine, day care, antenatal,intra-partum and postnatal care. Some staff raisedconcerns at their ability to improve clinical quality andstaff experience with such a large responsibility due toconcerns about women’s assessments and wait times inday care. The leadership team did not have a fulloversight of service provision on the maternity day careunit, and did not collect accurate date for admission andwait time data prior to our inspection. This was not in linewith Safer midwifery staffing guidelines, which set out theneed to monitor delays of 30 minutes or more inproviding triage care, missed or delayed care throughoutthe unit and full clinical examinations not being carriedout. All of these indicators represent potential ‘red flags’for safe midwifery staffing, therefore it is important theyare monitored to ensure safe staffing levels.

Vision and strategy

The service had a vision for what it wanted toachieve and a strategy to turn it into action,developed with all relevant stakeholders. The visionand strategy were focused on sustainability ofservices and aligned to local plans within the widerhealth economy. Leaders and staff understood andknew how to apply them and monitor progress.

The trust had been forced to review services amidstpublic concerns about safety and performance. Duringour inspection the trust issued a public statement whichconfirmed changes were ongoing stating, “We recognise,

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however, that the scale of change needed in ourmaternity service has not taken place quickly enough andwe need to fully embed further learning and changes toour culture.”

The trust vision for the planning, design and safe deliveryof services was founded in an inclusive multi-professionaltraining and audit program, using the BESTT program formaternity services. The framework provided a qualityimprovement program in maternity services to addressthe lessons learned from serious incidents and keythemes highlighted by HSIB and NHS Improvement.Workstreams were aligned to national guidelines, andfocused on reducing the number of stillbirths, admissionsto neonatal intensive care and skin tears duringchildbirth. The trust was entering year three of theirtransformation program and achieved eight out of 10 oftheir workstream targets. These principles were based onthe Safer Childbirth 2016 report, standards for theorganisation and delivery of maternity care.

A task and finish group was set up by the care groupwhich focused on workforce and job plans as part of thematernity transformation program had been introducedto improve key areas set out within the National MaternityReview report 2016 . The purpose of this is to providesenior presence in obstetrics and paediatrics to ensureappropriate cover of women’s and children’s services.

The task and finish group reported to the MaternitySupport Program learning and review committee, whichhad an externally appointed chair. The trust has beensupported in creating and complying with strictgovernance guidelines.

Culture

Most staff felt respected, supported and valued.They were focused on the needs of women receivingcare. The service promoted equality and diversity indaily work, and provided opportunities for careerdevelopment. The service had an open culturewhere women, their families and staff could raiseconcerns without fear.

Most staff felt the culture within the care group hadimproved over the last two years. Doctors and midwivesfelt respected, valued and involved with serviceimprovements.

In view of historic concerns with regards to the culturewithin maternity services; the midwifery leaderspromoted a culture of learning and continuousimprovement to maximise quality and improve outcomesfor women and babies. Staff were invited to attendmeetings for practice updates; leaders also sentnewsletters and emails of quality improvementmeasures. Furthermore, BESTT improvement audit datawas displayed on boards throughout the unit.

During the inspection, the trust had attracted a lot ofnational press attention due to a coroner’s review of twobabies that had sadly died in the past, while under thecare of the units. Midwives and support workers had beenplaced in the public spotlight, which some foundunsettling and upsetting for the families concerned. A fewstaff had been personally involved with case reviews, andothers had supported their colleagues throughchallenging times. Despite this, most staff we spoke withwere reflective, showed compassion for the families andwere passionate about the maternity unit and the carethat was currently provided. Many spoke positively andwere proud of the recent improvements that had beenmade.

Doctors told us they felt the culture had significantlyimproved over the last two years. Consultants wereapproachable and willing to listen to recommendations.Concerns were escalated appropriately by staff and asupport network was created which encouraged effectivetraining and development. Funding from the deanery wascited as a barrier to recruitment as this was based on thetotal number of births across William Harvey maternityunit. Although the deanery were proposing a change, thedetails were not clarified during the reporting period, andthe trust was recruiting more middle grade doctor.

The majority of staff had worked for the service for manyyears and staff confirmed they felt they were part of aworking family. Staff turnover was under 5%.

Staff were open and honest and understood theprinciples of duty of candour within maternity. Whenthings went wrong, staff would escalate to their managersand doctors, and complete incident reports.

In most areas of the unit, staff felt they were able to reportincidents without the fear of being liable. However, somestaff in antenatal services told us they felt incidentreporting for internal staffing or workload issues were not

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encouraged by the management team. We raised thiswith managers, who spoke with staff to reassure themthat reporting incidents helped inform and changepractice when necessary.

Although the trust had a freedom to speak up guardianand a whistleblowing policy, some staff we spoke withwere unaware of these systems which supportedtransparency within the workforce.

However, although most midwives acknowledgedimprovements in culture, several support staff at WilliamHarvey felt that there had been a lot of focus onimproving the service at Queen Elizabeth The QueenMother Hospital and that the William Harvey Hospitalimprovements had been delayed because of this.Support staff told us they felt frustrated by this. Supportworkers we spoke with felt there was no careerprogression or development from band 2 to band 3 andtheir workload had increased. This impacted on theirmorale and emotional wellbeing, and they feltundervalued.

On the whole, staff were supportive and appreciative oftheir relationships. Teams worked collaboratively andstaff spoke highly of the unit matron. Staff sharedresponsibilities and any conflict was resolved quickly andconstructively.

The trust promoted equality and diversity throughout theorganisation and beyond. Staff told us that they feltprotected characteristics under the Equality Act 2010were respected by managers and throughout the caregroup.

Governance

Leaders had recently improved the governanceprocesses throughout the service with support frompartner organisations. However, the newgovernance processes were not yet fully embedded.Staff at all levels were clear about their roles andaccountabilities and had regular opportunities tomeet, discuss and learn from the performance of theservice.

There had been improvements to multi-professionalsimulated training and investments had been made innew remote electronic fetal monitoring equipment. Themidwifery workforce had stabilised, and new escalationprocedures implemented. Out of hours safety huddles

were attended by all staff and compliance to this wasmonitored. The trust’s obstetric standard of careprocedure had been drafted and was due to bepublished. The trust supported by a maternitytransformation program had taken steps to mitigate risksto women, babies and their families.

The trust’s governance and management model wassupported by external third parties, which included NHSimprovement and commissioners. The maternityWomens and Childrens care group had beenreconfigured in 2018. They were previously included in amulti-speciality division, along with cancer, and had novoice within that division. This was the first inspectionsince the reconfiguration. New site leads had beenappointed to ensure that governance and improvementswere carried out.

The governance structure included a structure ofmeetings to ensure oversight, reporting and particularlyclinical engagement at each site. The structure wasdemanding on the triumvirate because meetings limitedtheir time to develop the strategy for the service anddeliver the necessary change at pace. They madesignificant progress despite this challenge. However, thepace of change was an issue as some of their key patientoutcome targets were not showing the targeted reductionin poor outcomes.

The trust was a member of the Clinical NegligenceScheme for Trusts (CNST) which handle clinicalnegligence claims against NHS providers. In August 2019the Trust declared compliance with year two of thematernity incentive scheme, which is designed toimprove quality and safety in maternity services.

However, when the submission was rechecked, the trusthad failed to meet two (safety actions 5 and 8) of the tenrequirements for the period between January 2019 andAugust 2019. The trust did not fully demonstrate aneffective system of midwifery workforce planning to therequired standard. Additionally, the trust were unable toevidence that at least 90% of each maternity unit staffgroup had attended an 'in-house' multi-professionalmaternity emergencies training session within the lasttraining year. This meant the trust were not able to assureNHS Resolution that they were compliant with all tenmaternity incentive scheme safety actions.

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The trust was supported by the NHS Maternity SupportProgram , which included support from a director ofmidwifery from a trust rated ‘Outstanding’ by CQC; aconsultant obstetrician and a consultant paediatrician, tosupport maternity make rapid and sustainableimprovements to services.

The Womens and Childrens care group interacted withthird-party providers including NHS Improvement toensure the service was governed and managedappropriately to co-ordinate safe, person-centred care.

Due to concerns highlighted by HSIB, NHS Improvementand other third party agencies had been working with thecare group to review and rationalise the governancestructure. Consideration had been given to reducing timespent in meetings to release time to focus on developingan agreed vision and service development plan for thecare group, underpinned by a workforce plan.

Quarterly external meetings were held with the HSIB andminutes confirmed that the board reported its oversightof the quality of care in the Womens and Childrens caregroup. Minutes confirmed that commissioners reviewedmaternity dashboard data, and felt that during thereporting period data looked positive. Reviews hadhighlighted similar themes, although the leadership teamcould provide evidence of a safety culture with increasingserious incident reporting and learning from outcomes.

The Womens and Childrens care group seniormanagement team met monthly. They had a strategy forcontinuous improvement in safety, which included anaccountable leadership team that included consultants,midwives, and neonatologists. The team consisted of thehead of midwifery, a consultant, the governance matron,the service manager and information lead. Minutesconfirmed that meetings discussed, budgets, nationaltargets, service delivery and activity.

Midwifery meetings were held at all levels, Matrons heldmonthly meetings to review services. Band 7 midwiveswithin the unit and the community setting would holdmeetings with each other to discuss staffing,implementation of new practice, compliance and futureplanned services.

The Womens and Childrens care group had createdprocesses to cascade learning from outcomes, changes

to practice and case reviews for all staff. These included,news-letters, internal emails to all staff and importantupdates at daily huddles, to make sure these wereembedded in practice.

Managing risks, issues and performance

Leaders used systems to manage performance,however, these were not always effective in all areasof the service. Leaders did not always identify andescalate relevant risks and identify actions to reducetheir impact. However, the service had plans to copewith unexpected events. Staff contributed todecision-making to help avoid financial pressurescompromising the quality of care.

Leaders had not always identified and escalated relevantrisks or identified actions to reduce their impact. Ourinspection noted that maternity managers failed toidentify a lack of incident reporting and assessment ofrisk on the day care unit. There was a lack of audit of waittimes for women attending day care and a for womendelivery babies alone in the bereavement suite. Also,although staff audited patient records they failed toidentify the lack of use of MEOWS score on the day careunit.

Following our inspection the trust provided assurance onimproved oversight of antenatal services by theleadership team, and the service now recorded whenwomen accessed the service. Staff were encouraged tocomplete an electronic incident reporting form forwomen waiting longer than one hour to be medicallyreviewed.

Risk was monitored through local and trust widemeetings. The care group provided a monthly quality andrisk report which was reviewed monthly at the qualitycommittee. Other than risks we identified on thematernity day care unit, we found risks on the risk registerwere consistent with the concerns shared by maternitystaff and there were current plans to address identifiedrisks such as the siting of Resuscitaire on the deliverysuite, the lack of space on day care, and doctorrecruitment issues. The maternity risk register wasreviewed monthly to identify any issues withinperformance. Information from the review meetings werefed through into the trust risk and governance monthlymeetings.

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The systematic program for clinical and internal auditmonitoring of quality, operational and financialprocesses, had been embedded into the care group.Doctors and midwives engaged with the program andcollected data from internal digital systems.

The BESTT transformation program and a qualitycommittee monitored and supported the transformationprogram against agreed key performance indicators.Project and trust meetings were held monthly.

The maternity serious incidents were reviewed at theserious incident panel. The chief nurse worked with themedical director to review and approve the final drafts ofroute cause analysis reports prior to submitting these tothe Clinical Commissioning Group.

The service had plans to cope with unexpected events.Managers had standard operating procedures for majorincidents. Potential risks were assessed when planningservices. Strategies included notifications to staff and thepublic of bad weather or seasonal flu outbreaks, andmanagers created action plans and reviewed staffinglevels.

Financial support was provided under a financial specialmeasures program. Finances were monitored by thirdparty agencies who supported the trust to purchaseessential equipment and digital systems to improve thequality of care for women and their families.

Managing information

The service collected reliable data and analysed itmost of the time. Staff could find the data theyneeded, in easily accessible formats, to understandperformance, make decisions and improvements.The information systems were integrated andsecure. However, data or notifications was notalways submitted to external organisations asrequired.

The leadership team reviewed the quality of informationit collected to improve performance. There weresufficient performance measures which were monitoredand reported. The trust contributed to national datacollection for MBRRACE-UK (Mother and Babies: ReducingRisk through Audits and Confidential Enquiries), ATAIN(Avoiding Term Admissions into Neonatal Units) andBESTT.

Quality and sustainability received sufficient coverage atrelevant meetings at all levels, staff had sufficient accessto information. The trust had a complex multi-layeredsystem for managing information. Key staff were assignedto different work streams and were responsible forimplementing, assessing and reviewing data, which wasfed back to the trust board.

The care group were working with NHS digital to create adigital patient health record, that women could access ontheir smart phone or computer. The unit contributed to anational working party which was trialling aspects of thenew digital healthcare records.

Consultants and matrons were responsible for ensuringthat information used to monitor, manage and reportquality and performance was accurate, valid andrelevant. Actions plans were reviewed at weekly meetingsacross the unit.

Engagement

Leaders and staff actively and openly engaged withwomen, staff, equality groups, the public and localorganisations to plan and manage services. Theycollaborated with partner organisations to helpimprove services for women.

Leaders had improved engagement with staff, clinicalengagement had been a priority and the care groupacknowledged this needed to be strengthened to supportthe quality improvements and changes in ways ofworking. The triumvirate engaged with the consultantbody for them to lead on developing the strategy andapproach to consultant cover. The care group had achange in clinical leadership and worked with them todevelop a safe sustainable consultant cover package.Through this engagement, questions were posed on thefinancial sustainability of 24 hour obstetric cover acrossthe care group .

The chief nurse chaired a monthly ‘getting to good’ groupwhere the care group discussed progress against theirCare Quality Commission action plan.”

The trust engaged with external agencies and strategieshad been put in place to improve services. Maternityreports were presented to the patient safety committeechaired by the chief nurse.

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There were positive collaborative relationships withwomen and third party organisations. The stillbirth andneonatal death charity, SANDS, had worked closely withmothers and the trust to create the ‘Twinkling Stars’bereavement suite, which was in line with best practice.

People’s views and experiences were gathered and actedupon to shape future services. The leadership team metquarterly with the East Kent Maternity Voices Partnershipto review women’s feedback and concerns. Thesemeetings provided updates from service users abouttheir experiences and informed the development ofmaternity services.

The trust collected patient feedback at the end of theircare. Women were issued with a friends and familyfeedback form which were either sent in via the post orcollected by community midwives. Patient feedback waspositive data confirmed that during the previous year,97% of women had reported a positive experience duringantenatal and postnatal care.

Managers involved staff in the planning and delivery ofservices throughout the unit. Staff told us the trustfunded a staff survey on training needs to inform thefuture development of training. Managers introduceddischarge co-ordinators to assist staff with theadministrative aspect of discharging women fromFolkestone ward.

Learning, continuous improvement and innovation

All staff were committed to continually learning andimproving services. They had a good understandingof quality improvement methods and the skills touse them.

The Womens and Childrens care group had been thesubject of national NHS scrutiny due to historic concernsabout patient safety and the higher than average numberof poor outcomes for new born babies. Pro-activeconsultants, doctors and midwives affected by theincreased scrutiny reviewed current evidence anddevised improvements to the continuous professionaldevelopment of all maternity staff. These improvementswere ongoing, and part of a three year redevelopmentprogram designed to respond to public concerns, andreduce poor outcomes for the women and families ofEast Kent.

Continuous learning, improvement and innovation wasencouraged and developed to improve care for womenacross the trust. Improvements in team working througha model of multi-disciplinary simulation training, usingreal incidents, was exemplary and mentioned in all thestaff interviews. The unit adopted a multi-professionalphysiological approach to fetal heart monitoring led by aconsultant at William Harvey Hospital.

There were standardised improvement tools andmethods in place to review and improve evidence basedpractice which included the implementation of the BESTTprogram.

The trust had created The Faculty of Multi ProfessionalLearning in Maternity in 2018 which contained stated ofthe art technology and equipment to support simulatedlearning in a multi-professional setting. Three practicedevelopment midwives supported by a consultantreviewed audits, planned and delivered training for arange of subjects.

The consultant had completed a global review of 30international maternal inquiries to highlight qualitymaternity care across the world. They identified threethemes: consistent language, reduced variations andformal leadership quality improvement and learning.Based on their research they introduced human factorstraining for all health care professionals involved inmaternity care, designed to improve communication andactions during emergency situations.

The trust had reviewed the evidence and updated itspractice for monitoring the fetal heart electronically.Maternity units cross-site adopted that the most up todate method of physiological interpretation of fetalwellbeing (cardiotachagraph) readings which was criticalto reduce neonatal hypoxia during childbirth.

Maternity services introduced TRiM (Trauma RiskManagement) in 2019. TRiM is a trauma-focused peersupport system designed to help people who haveexperienced a traumatic, or potentially traumatic event.TRiM practitioners have completed training tounderstand the impact dealing with trauma has on staff,and employs strategies for staff to assimilate trauma.TRiM provides emotional support for staff who otherwisemay not seek help after being involved with a traumaticevent.

Maternity

Maternity



Outstanding practice

• Midwives created a service to provide women withear plugs on the postnatal ward to help them sleep.

• Kanga wraps were available for women who chose tobreastfeed to optimise skin to skin care.

• The trust created a Faculty of Multi ProfessionalLearning in Maternity, and invested in state of the artsimulation equipment, which allowed all staffexposure to simulated ‘real life’ emergencysituations.

Areas for improvement

Action the provider MUST take to improve

• The trust MUST ensure it assesses the risks to thehealth and safety of women receiving antenatal careand treatment. Regulation 12(2)(a)

• The trust MUST ensure that standard operatingprocedures, used within William Harvey Hospital daycare, operate effectively. Regulation 17(1)

• The trust MUST ensure that it mitigates the risksassociated with using a combination of paper anddigital patient care records. Regulation 12(2)(b)

Action the provider SHOULD take to improve

• The trust SHOULD ensure it continues to monitorand mitigate any identified risks due to the siting ofResuscitaire on the delivery suite

• The trust SHOULD ensure that 85% of Doctorscomplete safeguarding training

• The trust SHOULD continue to monitor and auditantenatal day care admissions and wait times

• The trust SHOULD ensure that venousthromboembolism assessments are carried out tomeet national targets

• The trust SHOULD ensure its ward security systemmaintains a secure environment to which access isrestricted at all times

• The trust SHOULD consider its approach tosupporting mother’s to help babies to adapt to lifeoutside the womb within the first hour of birth.Including monitoring the cause of neonatalreadmissions under 10 days and reviewing theimpact of deploying one midwife to manage theelective section surgical list

• The trust SHOULD consider assessing the number ofplanned attendances against the number ofunplanned attendances to be able to respond to thedemand on the service

• The trust SHOULD consider creating a dedicatedperinatal mental health service for women in need ofadditional mental health support or specialistintervention in-line with NHS England’s PerinatalMental Health Care Pathways 2018recommendations

• The service SHOULD consider its approach topromoting infant feeding conversations duringpregnancy

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

Regulated activity

Maternity and midwifery services Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

Regulated activity

Maternity and midwifery services Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

Regulation

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


william harvey hospital - cqc

Documents