Royal Stoke University Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

The department had processes in place for shared learning. Reviews took place into care provided and learning was identified; there was a maternity dashboard in place. Staff were knowledgeable about the challenges at the service. Weekly risk meetings took place where leaders reviewed all term admissions to the neonatal unit and audited the care provided. Processes were in place around safeguarding, staff spoke positively about the safeguarding team and felt they could call them to provide any support. Staff completed safeguarding training. Staff were aware of escalation pathways and reasons for seeking escalation. The percentage of service users who were induced in line with national and local guidance in 2024 was consistently above 97%.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The hospital sought feedback on people’s experience. For example, a patient perspective maternity survey improvement plan was in place using 2023 data results. The trusts results were about the same as other trusts. CQC carried out an annual maternity survey, this survey looked at the experiences of 18,951 women, across 120 NHS trusts, who gave birth in February 2024 (and January 2024 for smaller trusts). Questionnaires were sent out between May and August 2024; responses were received from 176 people at University Hospitals of North Midlands NHS Trust.

The trust identified themes and trends from complaints, for example in the December 2024 complaints report it was identified there had been an increased in complaints around attitude of staff and poor communication. The service currently had 14 open complaints and of which 9 were overdue and over 28 days.

Managers reviewed incidents on a regular basis so they could identify potential immediate actions. Managers investigated incidents thoroughly. They involved women, birthing people, and their families in these investigations and recorded ethnicity as part of the review process.

Staff we spoke with responded both positively and negatively about the learning culture of the service. Results from the last staff survey showed, that staff divisional response rate was 55.58%, with divisional staff engagement score of 6.6. Highlights from the survey was that morale had increased from 4.7 to 5.2. Diversity and equality had dropped to .3. Burnout increased from 3.7 to 4.1. We saw actions were taken by the leadership team to improve areas highlighted as a concern, for example, increase diversity in workforce with internationally trained midwives. Staff were required to complete diversity, cultural curiosity in mandatory training along with gender inclusion training. Managers shared learning with their staff about never events that happened. The service had Lead Midwives for Development and Education who shared learning from incidents with staff. Trust had 46 incidents relating to neonatal and obstetrics that were under review of which 10 were patient safety incident, 2 were at the after-action review stage, 29 with MBRACE, 1 RIDDOR and 3 serious incidents. There were 23 incidents recorded as a near miss in April 2024 to June 2024. These were related to maternity assessment unit triage breaches and deferred induction of labour and midwifery/medical breaches. Some managers debriefed and supported staff after any serious incident. Some staff told us they were supported through feedback discussions, exploring incidents as well as potential improvements to the care of women and birthing people. Staff understood the duty of candour. They were open and transparent and gave women and birthing people and families a full explanation if and when things went wrong. Following the inspection, the service told us when sending letters to patients this was done so in the patients first language. Governance reports included the involvement of women and their families in investigation and monitoring of how duty of candour had been completed.

The department had processes in place for shared learning. Action plans were in place following the maternity and newborn safety investigation programme (MNSI) reports. Leaders completed midwifery led safety briefs where staff had an opportunity to highlight key safety issues to help prevent harm and improve patient safety; however, some staff feedback and said this did not always happen and were not always included in investigations or debrief.

The Maternity services trust board report (July to September 2024) showed 100% of perinatal deaths continued to be reported, reviewed and monitored in line with the National Perinatal Mortality Review Tool (PMRT). Following PMRT reviews of 14 cases, themes identified related directly to the Saving Babies Lives Care Bundle (SBLCB). The Directorate were working towards providing a thematic report in line with Saving Babies Lives Care Bundle (SBLCB) and the Maternity Strategy.

The trust PMRT report provides information on compliance with the perinatal mortality reviews. The service currently provides assurance to the Directorate, the Division, and the trust for compliance against the Clinical Negligence Scheme for Trusts (CNST) Maternity Incentive Scheme Framework (Year 6) standards for the investigation of stillbirths and neonatal deaths. The service is also required to share the report with Staffordshire and Stoke on Trent Local Maternity and Neonatal System (LMNS).

A thematic review by MNSI into some investigations conducted by the trust had revealed some themes related to the maternity service. The trust had a local maternity dashboard that identified any areas needing attention and for reporting to board.

Some women and birthing people we spoke with said that staff explained any risks of procedures with them, and any risk factors in their pregnancy so that they were well informed.

Results from the 2024 CQC Maternity Survey showed that women and birthing people rated advice on risks of induction and advice on benefits of induction ‘about the same’ as service users of other trusts.

We spoke with a woman’s partner who had experience a loss in 2021 and was extremely anxious with their second child. His wife was able to have a caesarean section at 35 weeks because of their anxiety and fear, “the care this time has been “outstanding” and has confidence in the clinical staff”.

Another woman and their partner told us they had attended MAU previously with 2 of their children, during this pregnancy, they said “kept informed and got they have got me straight in each time-has not had to wait for pain relief and communication has been good. The doctor came prepared and had read the notes”.

Another woman and their partner told us “My caesarean section went well, All staff knew their roles before my section started, all staff knew what they were doing”.

One partner we spoke with said “Since the birth of their son, doctors have seen him twice, including neonatal team. My mum was concerned about my son’s flaring nose and breathing, we raised our concern with the midwife, a doctor came immediately and kept me updated”.

However, one woman told us that “she was 37 weeks, “wished to make a formal complaint to PALS regarding her care when attending MAU”. She said, “she had 2 previous pregnancies with complications”. “Been waiting to be triaged as her baby’s heartbeat was fast”, “started contracting and in a lot of pain”, she told us “She had asked twice for pain relief, still not had any after requesting a couple of times, she asked to see a midwife, but they never came, a doctor arrived but was really rude, blunt.”

Staff we spoke with were aware of escalation pathways and reasons for seeking escalation. We saw ‘red’ and ‘amber’ flags displayed in triage, and staff could explain the escalation process for both clinical and staffing flags. A staff member on delivery suite we spoke with said that the use of the Birthrate Plus acuity tool was “a part of everyday practice” and if there had been an emergency, it would be retrospectively completed.

We reviewed trust latest data around induction of labour (IOL) which showed us that out of 252 IOL booked for September 2024, 98.02% IOL were completed in line with guidance, of the 252 inductions. Incidents for postnatal readmission showed a reduction in June 2024. The national average level of assurance was 3.30 %. The postnatal readmission rate was at 1.79% in June 2024, which showed a reduction from 2.88%. We saw that 25% of readmissions were women from ethnic minority backgrounds and 93% of readmissions received a review from a consultant obstetrician. The rates of consultant reviews remained static at 93%. We saw data provided by the trust that showed the top themes identified from readmissions were raised blood pressure, vaginal bleeding, suspected sepsis and back pain. There were 20 incidents of 3rd or 4th degree tears reported in June 2024, a reduction from previous data (29). The data reviewed showed no variation. All incidents confirmed were of low harm or no harm. The obstetric anal sphincter injury (OASI) rate was at 2.31% a reduction from 3.45%. The rate of OASI at the trust remains below the mean national data from national maternity and perinatal audit of 3.5%.

The 90% targets for sepsis screening and intravenous antibiotics (IVAB) administration were not always met. A plan was in place, a new sepsis leader had been recruited and working group was developed to address the issues. This was discussed at the maternity and neonatal quality and safety oversight group, August 2024 and we saw the meeting minutes, the sepsis role was relatively new role and that the Lead had undertaken a lot of work in a short period of time around education, awareness, ongoing monthly audits and action plans, staff were confident that this would improve due to the current focus. During the on-site assessment we found that risk assessments were mostly completed at every contact, and there was appropriate escalation/onward referral where required.

Staff knew about and dealt with any specific risk issues. Staff reviewed care records from antenatal services for any individual risks and used them to inform their clinical decisions.

Women had access to mental health support through the Perinatal Mental Health (PMH) service where clinics were offered at Royal Stoke University Hospital or at County Hospital. Staff could refer and seek assistance to support women and birthing people with risk indicators and/or mental health concerns.

Staff shared key information to keep women and birthing people safe when handing over their care to others. The care record was on a secure electronic care record system used by all staff involved in the person’s care. Each episode of care was recorded by health professionals and was used to share information between care givers.

Staff completed new-born risk assessments when babies were born using recognised tools and reviewed this regularly. During the 2023 inspection the service had closed their transitional unit and had been closed due to staff shortages. The service was now re-opened and taken positive steps increased staffing numbers to allow the unit to remain open.

Women and birthing partners we spoke with said “they felt safe in hospital”.

Another woman told us “The midwives are lovely and asked me about my mental health and the babies wellbeing”. “Only negative I have experienced is, there was one man in the theatre putting cannula in. Not nice or gentle, speaking to everyone badly.”

Community midwives told us that at every appointment, women are asked if they are safe. Acute staff told us they asked women and birthing people about domestic abuse, and this was a mandatory field in the electronic records system. Staff told us they were made aware of safeguarding concerns during shift handover.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. Staff were able to explain safeguarding procedures, how to make referrals and how to access advice.

The service had a safeguarding team who staff could turn to when they had concerns. Care records detailed where safeguarding concerns had been escalated in line with local procedures.

Staff we spoke with could give examples of how to protect women and birthing people from harassment and discrimination, including those with protected characteristics under the Equality Act (2010). Staff understood the importance of supporting equality and diversity and ensuring care and treatment was provided in accordance with the Equality Act (2010).

Staff followed the baby abduction policy and undertook baby abduction drills. Staff explained the baby abduction policy and we saw how ward areas were secure, and doors were monitored. The service had practised what would happen if a baby was abducted.

Various policies and guidelines were in place around safeguarding children and adults, and we saw they were up to date.

All clinical staff were required to complete both adults and children safeguarding levels 1 to 3. We saw training agenda for all levels of safeguarding training and topics covered areas such as modern slavery, female genital mutilation (FGM), child exploitation and many more.

Training records showed staff had not always completed both safeguarding adults and safeguarding children training at the level required for their role as set out in the trust's policy and in the national intercollegiate guidelines. Compliance rates for December 2024 varied between 77% and 97%. Trust annual training was September to September. Trust told us they were on target for staff to complete. This was an issue during previous inspection and remains to be challenging for the service to complete.

The department recorded details around safeguarding incidents, operational safeguarding activity and risks linked to safeguarding. Data included information such as how many unborn children were on child protection plans; early support plans and how many strategy meetings had been attended.

One woman spoke to us and said she had a “Genetic condition, and found liver issues, during pregnancy I contacted MAU due to reduced movement, staff were responsive I had no issues. I was induced at 35 weeks with no delays. I was involved in all decision making and was given options, I spoke with doctors and midwives.”

We spoke to another woman and her birthing partner that told us, “I was not left waiting, they are kind and respectful, helpful and were happy to show and support tube feeding”.

Another woman and birthing partner we spoke with said, “I have been checked regularly, overall, a positive experience”.

However, one woman told us “I was denied gas and air and in agony, midwife said I was not in established, rush to get to another opinion as I was known that I dilate really quickly, I delivered within 5 minutes, my husband missed birth as I didn’t feel listened to at this point”.

Staff we spoke with were aware of escalation pathways and reasons for seeking escalation. Women had access to mental health support through the Perinatal Mental Health (PMH) service where clinics were offered at Royal Stoke University Hospital. Staff could refer and seek assistance to support women with risk indicators and/or mental health concerns. There was a named doctor allocated to triage between the hours of 8am-8pm. During our focus groups with midwives from various maternity services told us that they could usually get support from a doctor at night when needed, and that the flow co-ordinator could help to track them down if not immediately available. Some midwives told us that the success of escalation was dependent on who you dealt with, and some were more supportive than others. Staff told us there were times a “disconnect between maternity and neonates”, it can be “us and them”, “I have raised this, keep but not listened to”. During the inspection from various of junior staff, “Hierarchy with doctors”, “look down upon me” “I’m junior, other midwives have same issue, mainly younger midwives minimise what we’re saying”. “Sometimes, obstetric team look at you”. Staff told us they lacked cardiotocography (CTG) monitors. CTG monitors is a widely used to assess fetal well-being by identifying babies at risk of hypoxia (lack of oxygen). During our inspection, we saw there were shortages of CTG equipment and not enough to manage women safely and effectively. On ward 206, we observed staff looking for CTG monitors and there weren’t any available. Staff told us they had to prioritise who to monitor depending on concerns of women and reduced movements. We raised this with the leadership team who told us they had recently purchased monitors, and that staff should have access to the equipment.

The service used nationally recognised tools to identify women and birthing people at risk of deterioration, this included national tools such as the Modified Early Obstetric Warning Score (MEOWS) for women and birthing people. We reviewed MEOWS records and found staff completed them and knew how to escalate concerns to senior staff. However, on the day of inspection we could not be assured that all staff used these tools correctly. During the inspection we observed staff changing blood pressure cuffs sizes inappropriately thereby reducing the patients risk score. This could potentially cause risk to women and birthing people not being identified as deteriorating and appropriate escalation taken in a timely manner. This was also raised during 2023 inspection. We raised this concern with the senior leadership, and they assured us that this was not their common practice and to be assured that this would be dealt with. Staff completed a quarterly meows audit in each department, and we saw samples of audits for ward 205 and 206 which was at 100%. Staff shared key information to keep women and birthing people safe when handing over their care to others. The care record was on a secure electronic care record system used by all staff involved in the person’s care. At the time of the inspection approximately 95% of all staff groups had completed their yearly appraisal. Leaders audited how effectively staff monitored women who presented with reduced fetal movements. An audit in June 2024 showed fetal monitoring compliance was over 90%. An audit in June 2024 showed 90% of women had been monitored throughout their labour using continuous use of (CTG) every hour following ‘fresh eyes’ guidance (checks completed hourly by staff). The maternity triage waiting times audit for June 2024, showed midwives reviewed 91% of women within 15 minutes of arrival; however, this meant that 9% of women were seen outside of target times.

People we spoke with told us they were triaged quickly and did not experience delays to be seen.

Women and partners told us the areas they had been was clean and said they had no issues with facilities.

We saw there were no posters in other languages on display within the services. One midwife told us they found this very difficult to get this changed within the trust, many staff had explained to senior leaders that not all women have access to devices to have the maternity App and finding information in their preferred language. Some staff felt strongly that there was still a need for leaflets for information in other languages.

Staff cleaned equipment after contact with women and birthing people. Staff cleaned couches between use in the antenatal clinic and it was clear equipment was clean and ready for use with ‘I am clean’ labels to state when it had last been cleaned.

Staff regularly checked birthing pool cleanliness following a standard operating procedure and tested the water for legionella.

MAU had ward clerks, who had oversight of waiting room.

The service ensured that telephone triage staff were always available to take calls and were never asked to move to another department.

Some staff running antenatal clinics told us there were not enough rooms to run clinic effectively and this at times caused unnecessary delays and waiting times for both staff and women.

The service had suitable facilities to meet the needs of women and birthing people's or their families. We reviewed the service resus trolley and found all checks had been completed and compliant including resuscitare checks. We saw a cupboard for storage of control of substances hazardous to health regulations (COSHH) in the sluice was unlocked. We raised this with nursing team to ensure that they were made aware of this. Ligature risks in both bereavement suite was seen, blind cords on the back of doors. We raised this with the nursing team and this was immediately rectified. Call bells were accessible to women if they needed support and staff responded quickly when called. However, signage and information leaflets were not visible in-patient waiting areas in languages representative of the local population. The design of the environment followed national guidance. The maternity unit was fully secure with a monitored entry and exit system. We found the service had made significant improvements to the triage unit (MAU) and the positive changes made around the estates work. We saw the new triage area appeared to provide a much better experience for the women, as well as providing a safer and more joined-up service. We were informed that a difference in the running of the unit has been a change to the governance structure, with the neonatal unit now sitting under the maternity umbrella opposed to child’s health. Senior teams told us this had been a significant factor in improving pathways, relationships and the operating of the maternity service. the transitional care unit was now open to full capacity of 10 beds and staffed by the neonatal team whilst continuing to work closely with the post-natal midwives. The unit re-opened in November 2024 and has gradually increased capacity, providing space where mothers and neonates were able to remain together, whilst also receiving all the necessary care they required prior to discharge.

At the time of the 2023 inspection, the service was in the process of updating their CTG machines, this was still in progress during our recent inspection, staff told us and we saw the service did not have enough CTG monitors, we observed this during our inspection, staff were frequently trying to find equipment that were not in use. We saw many CTG monitors were out of order and waiting to be fixed by the clinical technology.

There was a well-structured team made up of a range of midwifery service and allied professionals, designed to meet the needs of people who accessed and used the services.

People we spoke with were mainly positive about staffing levels and delays within the service was communicated to those waiting to be seen.

We found there were sufficient medical staff working at the service in line with national standards in relation to the number of births. Current medical vacancies were, 4 whole time equivalent (WTE) consultant specialising in perinatal mental health, fetal medicine, ambulatory care and endometriosis. 3 WTE advanced training fellows, 2 WTE research fellows and surgical/robotic first assistant. The obstetrics and gynaecology medical staffing team routinely audit all locum cover on a monthly basis against compliance. The audits and data are held centrally within medical staffing and overseen by their management team and shared with the obstetrics and gynaecology operational team on a monthly basis. The service made sure staff were competent for their roles. There was a preceptorship programme for newly qualified midwives, and this included competence assessment in different skills. A maternity passport had been introduced for agencies and locum staff, and to obtain this they had to attend all mandatory training sessions and be signed-off of all procedures. The service had a good skill mix and availability of medical staff on each shift and reviewed this regularly. The service always had a consultant on call during evenings and weekends. Managers supported medical staff to develop through regular, constructive clinical supervision of their work. Medical staff told us that they felt supported to do their job through clinical supervision and were given the opportunities to develop.

The service reported maternity ‘red flag’ staffing incidents in line with National Institute for Health and Care Excellence (NICE) guideline 4 ‘Safe midwifery staffing for maternity settings (2015). A midwifery ‘red flag’ event is a warning sign that something may be wrong with midwifery staffing.

The service offered a supernumerary shift co-ordinator who had oversight of the staffing, acuity, and capacity to offer 1:1 care during active labour; The service also offered flow-co-ordinator with the role of flow improvement throughout the service.

The service managers had the resources to adjust staffing levels daily according to the needs of women when staffing was particularly challenging. The service funded midwifery apprentice positions as well as recruiting international midwives. Since the 2023 inspection, the service was agreed a business case for further funding. In October 2024, trust recruited newly band 5 midwives, and internationally trained midwives, along with midwives returning to the organisation. The service was staffed in line with BirthRate Plus recommendations. We saw further assurances around the midwifery attrition and retention rates, the trust remained the lowest both nationally and regionally; 100% of the trust newly qualified midwives over the last 2 years had remained with the organisation. Current vacancies was for maternity support worker band 3 (3.59 WTE) and maternity support worker band 4 (1.0 WTE). Staff undertook a mandatory training package and compliance with most topics varied between 50% to 90%. Trust annual training figures ran from September to September, senior teams told us they were on target (95%) for completion. However, mandatory training remains to be an issue and challenging for the service to complete.

One woman told us they had raised an issue around the toilet in their bay as it was covered in blood and could not use it, and this meant she had to leave her baby and use the toilet further down the ward. “However, overall, It’s been really good, I am so relaxed I can't believe it”.

Women we spoke with stated they saw and heard staff washing their hands and using alcohol gel before treating them. They also said that staff used personal protective equipment (PPE) when undertaking procedures such as examinations.

Staff followed infection control principles, including the use of personal protective equipment (PPE). Leaders completed regular infection prevention and control (IPC) and hand hygiene audits.

The staff we asked about IPC did not have any concerns, and said if they had any concerns, they had access to IPC leads or champions for advice.

Maternity service areas were clean and had suitable furnishings, which were clean and well-maintained. MAU had recently been refurbished and the ward appeared to be visibly clean in clinical and non-clinical areas. Cleaning audits were completed, and records were up to date demonstrating that all areas were cleaned regularly.

Staff regularly checked birthing pool cleanliness following a standard operating procedure and tested the water for legionella.

There were infection prevention and related policies available for staff.

Data showed hand hygiene audits were completed every month in all maternity areas. In the last year compliance was consistently above 96%.

Women we spoke with said that they received sufficient pain relief and a choice of what they received.

Other women said they did not experience delays when pain relief medication was required.

Staff told us they had ongoing issues recruiting pharmacist, pharmacy technicians only visit clinics.

Staff reviewed each person’s medicines regularly and provided advice to women and birthing people and carers about their medicines. The pharmacy team supported the service and reviewed medicines prescribed. These checks were recorded in the prescription charts we checked.

Staff completed medicines records accurately and kept them up to date. Midwives could access the full list of midwives’ exemptions, so they were clear about administering within their remit.

Staff stored and managed all medicines and prescribing documents safely. The clinical room where the medicines were stored was locked and could only be accessed by authorised staff. Medicines were in date and stored at the correct temperature.

Staff checked controlled drug stocks daily. Staff monitored and recorded fridge temperatures and knew to take action if there was variation outside the ideal range.

Staff followed systems and processes to prescribe and administer medicines safely. Women and birthing people had paper prescription charts for medicines that needed to be administered during their admission.

Venous thromboembolism (VTE) assessments were mandatory which followed the trust antenatal and postnatal thromboprophylaxis policy. VTE assessments had been completed.

There was a clear process in place for managing and reporting national patient safety alerts for medicines. Staff were able to talk through a recent patient safety alert and describe the action taken. Processes were in place for reporting medicine errors or incidents and a clinical pharmacist attended weekly governance meetings and discussed any incidents reported.

There was an increasing number of medication incidents reported on the neonatal unit and a thematic review was ongoing. Final report, once completed will be shared with the CQC.