South Tees Hospitals NHS Trust has been told to improve its maternity services after a care watchdog expressed concern about staffing levels and an environment that was not fit for purpose.
The Care Quality Commission (CQC) also highlighted the lack of a birthing pool at Middlesbrough’s James Cook University Hospital with a standard bath being used instead, which was declared unsafe.
In response the hospital trust said it was continuing to seek investment to improve the environment in maternity services and said safety was its “top priority”, while a “comprehensive” action plan had been drawn up to address identified weaknesses.
The CQC said maternity services at both James Cook and the Friarage in Northallerton required improvement overall, having not come up to scratch in the ‘well led’ category and in the former’s instance for being safe.
Carolyn Jenkinson, CQC’s deputy director of secondary and specialist care, said: “When we visited maternity services at South Tees Hospitals NHS Foundation Trust we found leaders were generally visible and approachable for staff, as well as people using the service and their babies.
“However they didn’t always understand and manage the priorities both maternity services faced in a timely way.
“At the Friarage Hospital, the maternity unit was sometimes closed for births as staff were required to work at The James Cook University Hospital instead, due to low staffing levels.
“This made it difficult for people to plan a birth there.
“We found areas of concern at The James Cook University Hospital.
“For example, there was no birthing pool on the delivery suite or on the midwifery led unit.
“Staff used a standard bath instead of a birthing pool, which was unsafe and was putting people at risk due to the design of the room and the bath.
“Once this was highlighted to the trust, they stopped immediately.”
She added: “Leaders were highly responsive and engaging in relation to other concerns we raised with them during the inspection and acted promptly to improve the standard of care they were providing.
“We will continue to monitor both services, so the trust can build on where it’s providing good care and make improvements where they’re needed.”
At James Cook an inspection found the maternity service did always have enough staff and levels did not always match planned numbers, “which could put safety of women, people using the service and their babies at risk”.
The CQC also described various aspects of the environment as “not fit for purpose” with implications for safety, efficiency, privacy and dignity.
It said staff assessed risks to inpatients, but did not always act on them to remove or minimise risks.
The findings will come as a blow to the South Tees trust, which employs about 9,000 staff and serves 1.5million people, however it continues to retain its ‘good’ overall rating received last year as do both the main hospitals it operates.
The CQC said infection risks in maternity services were managed well and there was good engagement with users and the community, while managers ensured staff were suitably competent and those working on wards were focused on the needs of those being cared for.
In respect of the Friarage, it did not always have enough midwifery staff, or they were “frequently deployed” to the James Cook University Hospital.
It criticised governance from leaders stating that the systems in place did not consistently monitor the effectiveness of the service being delivered and manage risk well.
However safety aspects were managed well with maternity staff at the Friarage understanding how to protect women from abuse, assessing risks to them adequately, acting on them and keeping good care records.
Dr Deepika Meneni, clinical director for the trust’s maternity services, said: “The safety of those in our care is always our top priority and every member of our maternity team is dedicated to providing the best possible care.
“We are pleased that the reports reflect areas of outstanding practice, as well as highlighting those areas where we know we need to make further improvements.
“All of the areas identified by the CQC for improvement are being addressed through a comprehensive action plan and many of these have already been completed.
“This includes successfully recruiting midwives to all our vacancies.
“We are proud of our team for the hard work, professionalism and caring attitude that they show each day and that is reflected in our excellent patient feedback and in how closely we work with the parents and parents-to-be who make up our local Maternity Voices Partnership.”
The trust said there was ongoing recruitment to support maternity services across James Cook and the Friarage in addition to the successful recruitment of all newly qualified midwives who trained at the trust last year.
Meanwhile, there were planned improvements to the environment at James Cook, including the installation of a new birthing pool, which required some internal reconfiguration of the building, with water births still being offered at the Friarage in the meantime.
The organisation highlighted a number of areas which were found to be outstanding, including transparency and accountability and special support that was provided for birth parents and foster carers if a baby is placed into the care of a local authority.
Middlesbrough South and East Cleveland MP Simon Clarke said it was important to focus on the findings constructively to “ensure the best possible care for every mother and baby in the area”.
He said he had “full faith” in the dedication and expertise of hospital staff working in maternity, adding: “I know they are committed to addressing the areas for improvement identified in the report and it’s their hard work and professionalism that are key to providing the high-quality care our community deserves.”
What else did the report say about maternity at James Cook?
The CQC said the inspections carried out were at short notice, with 30 members of maternity staff being spoken to at James Cook, and included the maternity assessment triage facility there, delivery suite, the midwifery led unit, the antenatal and postnatal wards, obstetric theatres, and the day assessment unit.
Mandatory training in key skills was provided to staff with the hospital generally making sure most staff completed it.
Staff said they sometimes had to complete mandatory training in their own time because shifts were often very busy and there was no protected time for this, although the trust advised that time was given back for any training done in an employee’s own time.
In safeguarding terms, the report said most staff had training on how to recognise and report signs of abuse in those giving birth and they knew how to apply it.
The report said all areas of maternity at James Cook were visibly clean, along with equipment.
However the design of the premises and facilities available was not entirely suitable and the way in which they were maintained did not always keep people safe.
Environment issues were said to be “on the risk register” and the hospital was consulting an architect about improvements.
Detailing concerns about a standard bath being used instead of a birthing pool, it said:
“This was putting staff, women and birthing people at risk because it was not possible to move a bed into the bathroom area or control the water level quickly, nor fit the required number of staff around the bath to assist in an emergency.
“It was not possible to control water temperature or clean the bath in line with recommendations.
“This practice was highlighted in a Healthcare Safety Investigation Branch report in August 2023.
“Leaders were not aware of this practice, but responded to our concerns to ensure it stopped with immediate effect.”
It also said the trust had not been able to assure itself that staff could safely evacuate people from the bath in case of an emergency.
In some instances women also had to share bathrooms, although this was being minimised.
Another area of concern was said to be the security of the delivery suite at James Cook, in particular the ease with which it could be exited by simply pressing a button, although this was being addressed.
Staff carried out safety checks of specialist equipment with records showing that resuscitation equipment was checked daily.
On midwifery staffing levels, the report said: “Staff told us they did not get breaks; they were rarely fully staffed and were burned out.”
It also said there had been 105 so-called ‘red flag’ incidents, or warnings, associated with maternity staffing between July 2022 and July last year and the service had high vacancy, turnover and sickness rates.
‘Bank’ or temporary staff were used to fill some staffing gaps.
However in terms of medical staffing, the service generally had enough medical staff with the right qualifications, skills, training and experience to keep women and babies safe from avoidable harm, and to provide the right care and treatment.
Staff generally also felt respected, supported and valued.
Records were clear, up to date, stored securely and mostly easily available to all staff providing care, while staff generally followed systems and processes to prescribe and administer medicines safely.
Any incidents were managed and investigated and lessons learned shared, and when things went wrong, staff apologised and gave people honest information and suitable support.
The CQC said the trust must take action to comply with its legal obligations including
:: Ensure staff complete regular skills and drills training
:: Review the escalation or surge process to ensure that an on call rota is effective and there is not an over reliance on specialist midwives which impact negatively on staffing out of hours
:: Follow up all governance and risk concerns and ensure any mitigations applied are effective and reviewed
:: Address the environmental and equipment shortfalls that affect the safety, privacy and dignity of women, birthing people and babies.
Figures show that between April 2021 and March 2022 a total of 4,630 babies were born at the James Cook.