The Care Quality Commission (CQC) has told Gloucestershire Hospitals NHS Foundation Trust that it must make immediate improvements to its maternity services at the Gloucestershire Royal Hospital, following an unannounced inspection in March and April 2024.
CQC inspected to follow up on the improvements made since its previous inspection, after CQC issued a warning notice to the trust.
In May following the inspection, CQC imposed urgent conditions on the trust to make improvements ensuring the safe treatment of women and people using the service, and also to improve how it was being led and managed. These conditions are still in place in January 2025 and the trust reports to CQC updating on the progress of their action plan on a fortnightly basis.
Overall, maternity services have been re-rated inadequate as have the ratings for safe and well-led. Due to the focused nature of the inspection, CQC looked at some areas of how effective, caring and responsive the service is but not enough to re-rate these key questions which remain good from their previous inspection.
Catherine Campbell, CQC's head of hospital inspection, said:
“Our inspection of maternity services at Gloucestershire Royal Hospital revealed that while we saw some positive changes, not enough work had been done yet to address the basic issues around safety.
“We were still concerned about how the trust managed systems to identify risks to mothers, babies and people using the service. Some people told us they didn’t always feel safe in the department.
“Leaders didn’t properly induct agency staff or provide access to essential systems, causing care delays. For example, agency midwives didn’t always have security door fobs and would need to rely on other staff during emergencies, creating potential risks to people’s safety due to those delays.
“Leaders were using systems to manage the department that weren’t effectively identifying or addressing areas for improvement and learning from these didn’t result in changes that would improve care. For example, cases of women bleeding heavily after giving birth which is life-threatening were continuing to rise when compared with previous months, but no effective action had been taken to address it.
”It was a concern that staff felt there wasn’t a proactive safety culture. While some felt they hadn’t been supported after raising concerns and were reluctant to do so again as a result.
“However, the trust had improved staffing numbers and ensured staff completed mandatory training. New midwives and those who were internationally recruited were receiving extra support from practice development midwives.
“The conditions we imposed at the time of inspection are still in place to ensure that immediate improvements are made, around safety and management of the service. We will continue to monitor the trust closely, returning to check that the necessary improvements have been made.”
Inspectors found:
- Leaders and staff engaged with people, staff, and a variety of stakeholders to plan and manage services, but they didn’t always create clear action plans to drive improvement
- Some of the national risk assessment tools used by the trust to reduce risks for women, people using the service and their babies were not used in their entirety and missed some of the risks
- Staffing numbers had improved although there were still concerns about staffing levels, skill mix and support provided for staff. Gaps in rotas were filled using regular bank or agency staff
- Processes to manage poor staff performance often took a long time to complete and left staff feeling hesitant to raise further concerns. Non-registered staff didn’t feel recognised for their contributions in the same way registered midwives were.
However inspectors also found:
- Inspectors saw an example of translation services to support people whose first language was not English
- Recruitment processes were thorough, safeguarding people who use the service from harm or abuse
- Safety Champions for maternity had started a programme of attending all areas of the maternity service. This was to work alongside and engage with staff to gather their views and create a more open culture.
The report will be published on CQC’s website in the coming days.