Bedford Hospital

We carried out this unannounced focused inspection to follow up on concerns from our inspection in November 2020. At our last inspection we rated the service as inadequate and issued the trust with a section 29A warning notice which gave instructions for the trust to significantly improve the areas identified.

Since the COVID-19 outbreak we have been adapting our approach to inspection whilst addressing risks, which delayed our return to the service.

Bedford Hospital is operated by Bedfordshire Hospitals NHS Foundation Trust and provides maternity services to women living across the county of Bedfordshire.

The maternity unit at Bedford Hospital provides a comprehensive range of inpatient and outpatient services from pregnancy, birth and post-natal care.

The maternity unit is located in the Cygnet wing at Bedford Hospital. The service provides consultant and midwife-led care for both high and low risk women. The consultant-led delivery suite is located on the first floor and has eight delivery rooms, one dedicated obstetric theatre and a two-bedded recovery bay for post-operative women. There is also a dedicated bereavement suite called the Butterfly room.

The Acorn suite is the midwife-led birthing unit and consists of three low-risk birthing rooms and is situated at the far end of the delivery suite.

There is a 24-bedded joint postnatal and antenatal ward, called the Orchard ward located on the second floor of the Cygnet wing. This ward consists of five four-bedded bays and four side rooms, two of which are amenity rooms, which are normally available to women who wish to pay for a private room, although this option had been suspended during the COVID- 19 pandemic. Orchard ward also contains the four-bedded maternity day assessment unit.

The maternity service also has an antenatal outpatient department situated on the first floor of the Cygnet wing. The department includes screening services, the early pregnancy assessment clinic, and antenatal clinics. Community midwives provide care for women and their babies both during the antenatal and postnatal period. They also provide a home birth service.

The maternity service is managed through the trust’s maternity clinical service line which is part of the women’s health and sexual health clinical service line. The current leadership structure includes a clinical director, a senior general manager, and a director of midwifery. This triumvirate is replicated on both hospital sites with a clinical lead, general manager and head of midwifery. Obstetricians, matrons, and senior midwives also support the senior leadership team.

We last inspected the maternity service at Bedford Hospital in November 2020 when we identified a number of concerns regarding staffing numbers, staff competency, poor triage and escalation processes, poor multidisciplinary team working, records were not held securely, and the culture did not encourage staff to share concerns. As a result, a section 29A warning notice was issued under the Health and Social care Act 2008 which required the trust to make improvements to reduce risks. The service was rated as inadequate overall; safe and well led were rated inadequate and effective was rated as requires improvement.

We did not rate this inspection as we used our focused methodology. Consequently, the rating for the service remains inadequate.

We did not rate this inspection. Our previous rating of inadequate remains:

• The service compliance with mandatory, safeguarding and competency based specialist training was generally below the trust target.
• Not all staff maintained effective infection control and prevention for all patients.
• The maternity triage area was not fully suitable to the service needs.
• Safety tools were not always fully used or recorded.
• The service did not have enough midwifery staff; however, we did not see any evidence of this impacting negatively on women’s safety.
• The service did not always have enough medical staff with the right qualifications, skills, training and experience, although we did not see any evidence of this impacting negatively on women and baby’s safety.
• Women’s care and treatment records were often loose papers with no structure.
• Women were not always able to access specialist nutritional support in a timely way.
• The leadership team were relatively new and had not had sufficient time to embed changes.
• Staff did not always feel supported and valued. Some staff reported that they did not raise concerns as a result of challenges by some leaders.

However:

• Staff understood how to protect women from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
• The service generally controlled infection risk well. Staff used equipment and control measures to protect women, themselves and others from infection. They kept equipment and the premises visibly clean.
• The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use them. Staff managed clinical waste well.
• Staff generally completed and updated risk assessments for each woman and took action to remove or minimise risks. Staff identified and quickly acted upon women at risk of deterioration.
• Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank and agency staff a full induction.
• Managers regularly reviewed and adjusted staffing levels and skill mix and gave locum staff a full induction.
• Staff kept records of women’s care and treatment. Records were stored securely and easily available to all staff providing care.
• The service used systems and processes to safely prescribe, administer, record and store medicines.
• The service managed safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
• The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance.
• Staff monitored the effectiveness of care and treatment. They used findings to make improvements and mostly achieved good outcomes for women.
• Staff gave women enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for women’s religious, cultural and other needs.
• The service made sure staff were competent for their roles.
• Doctors, nurses and other healthcare professionals worked together as a team to benefit women. They supported each other to provide good care.
• The service was accessible seven days per week.
• It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff.
• Leaders had the skills and abilities to run the service. Service leads understood and managed the priorities and issues the service faced. They were visible and approachable in the service.
• Staff were focused on the needs of women receiving care.
• Leaders operated effective governance processes, throughout the service and with partner organisations. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service.
• Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact. They had plans to cope with unexpected events.
• Leaders and staff actively and openly engaged with women, staff, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for women.
• All staff were committed to continually learning and improving services.

How we carried out the inspection

We visited clinical areas in the service including the delivery suite, Acorn suite, Orchard ward and the maternity day assessment unit. We spoke with 29 staff, including service leads, midwives, medical staff and maternity care assistants. We reviewed nine sets of women’s records and observed staff providing care and treatment to women.

Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activities. We carried out a focused inspection related to the concerns raised, this does not include all of our key lines of enquiry (KLOEs). As a result of this inspection ratings for this service remain unchanged. Safe and well-led are rated inadequate, and effective rated as requires improvement. Overall, the service was rated as inadequate.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.