National review of maternity services in England 2022 to 2024

As part of our work, we commissioned The Healthcare Improvement Studies Institute (THIS Institute) at University of Cambridge, with RAND Europe to evaluate our inspection programme and to identify where we can improve.

The evaluation had 2 objectives:

• to characterise what good safety culture looks like in maternity services and the factors underpinning it
• to evaluate the national maternity inspection programme to maximise learning.

Here, we look at the findings from the programme evaluation.

THIS Institute interviewed CQC inspectors, staff managing the programme and staff from inspected provider organisations (23 interviews in total). They also reviewed internal and external programme documents, including anonymised inspection notes, and undertook a literature review of the evidence for regulation with a particular focus on inspection.

Key findings from the evaluation include:

• The programme ensured that maternity remains a high priority in NHS trusts and gave greater momentum to current improvement initiatives.
• Our focus on equality and diversity further highlighted these issues in maternity settings. Although inspectors were keen to include these considerations in their inspections, the focus was brought in later in the programme. Therefore, assessment materials were not always designed in a way that made it easy for inspectors to consistently capture relevant information.
• The programme placed demands on maternity services, which sometimes struggled to provide the information we requested at short notice ahead of inspections. Our inspection visits were perceived to add to already high levels of scrutiny from regulatory and quasi-regulatory bodies.
• The scale of issues identified on inspection meant that the process was more involved than had been anticipated – both for services and for CQC colleagues. The programme was planned and delivered very quickly, which also introduced challenges.
• Some staff in maternity services said they were uncertain about the effectiveness of the inspection process, which made them question the consistency and validity of the ratings produced in some cases. Staff told us this was partly because of how they perceived the inspectors used discretion when making judgements, and that they felt the reasoning behind judgements was not always made transparent. Some staff also shared that including inspectors in the programme who had less direct maternity expertise and experience might have resulted in judgements they felt to be less robust.

Following the evaluation and feedback from inspectors, we are exploring what changes we can make to improve inspections of maternity services.

The role of inspection

The National Maternity Inspection Programme used inspection as the primary tool for gathering evidence. The evaluation therefore focused on the role of inspection as an effective regulatory tool.

From the evidence reviewed, the evaluation reported general agreement that inspection is a vital part of effective and accurate regulation, since some aspects of quality, safety, culture and leadership are difficult to assess through secondary sources. To gather enough evidence across the wide range of factors that contribute to high-quality care, inspections need to use methods that look at specific and observable activities as well as more complex features such as culture, vision and innovation.

The evaluation highlights the benefits of principle-based inspection, rather than inspection that is based on the use of strict rules and prescriptive standards. Principle-based inspection allows inspected organisations to respond to regulators in flexible, adaptive, and reasonable ways. It empowers professionals to take ownership while also supporting inspectors to exercise discretion. However, in applying discretion, the consistency of inspections may be challenged.

Going forward, inspections will remain an important part of how we regulate. Since delivering the National Maternity Inspection Programme, we have moved to our new assessment approach. As part of this approach, we’ll gather evidence to support our judgements in a variety of ways and at different times – not just through on-site inspections. This means inspections will support this activity, rather than being our primary way to collect evidence. We know that observational methods, such as inspection, have a clear role in capturing evidence about cultures in care settings. The findings from the National Maternity Inspection Programme presented in this report suggest there is a clear need to continue to use inspection as part of our assessment of maternity settings.

The learning from the evaluation has given us helpful principles to consider when delivering inspections. This includes how we might use additional checks and balances to review judgements made by inspectors.

Learning opportunities

In addition to considerations for how we undertake inspection activity well, the evaluation has helped shape the following learning opportunities:

• Improve the alignment with other oversight bodies, including those who provide improvement support, to reduce demands on services. This can include careful consideration of the scheduling of visits and timing of information requests. It could also involve timely data sharing between us and other bodies to enable comprehensive judgements of risk that tell the whole story.
• Identify opportunities to use data that is specific to maternity services and distinct from data at trust level to help us delve deeper into risks and issues in a more targeted way. This will help us with our continuous monitoring of risk and reduce the scale of issues uncovered in inspection.
• Continue to improve how we assess equality and diversity in maternity settings to ensure this remains a central focus and key priority for services. This can include improving internal processes and systems for evidence gathering of specific equality and diversity information.
• Focus on building trust and positive relationships with maternity settings to encourage regulation to be seen as a factor that contributes to improvement. Positive feedback from inspected trusts as part of the programme welcomed kindness from inspectors and a thoughtful and supportive approach.
• Share more information with providers due to be inspected as part of focused programmes to create shared expectations and improved awareness of the information we will be reviewing.
• Improve how we plan focused programmes to ensure there is sufficient time to provide further learning and development opportunities to inspectors who have less experience in specialised settings and to ensure we can secure the involvement of specialist advisors.

Despite the challenges, regulation remains critical in maintaining safe levels of care and driving improvements in sectors like maternity, where we know systemic issues persist. We have a clear role in outlining the quality of care that people should expect and holding services to account if they fail to meet these standards. Learning from this evaluation will help us to carry out this role in the future.