North Yorkshire Overview and Scrutiny Committee

Report of Sascha Wells-Munro, Director of Midwifery and Dawn Parkes, Chief Nurse Designate, York and Scarborough Teaching Hospitals NHS Foundation Trust

York and Scarborough Teaching Hospitals NHS Foundation Trust’s response to the publication of the Care Quality Commission’s (CQC) report into maternity services and the Single Improvement Plan

The purpose of this report is to provide the North Yorkshire County Council Overview and Scrutiny Committee with assurance in relation to the approach the Trust is taking to respond the issues identified by the Maternity CQC inspection undertaken between October 2022 and March 2023.

1.    Background

York and Scarborough Teaching Hospital NHS Foundation Trust was last inspected by the CQC between October 2022 and March 2023. The inspection looked at Emergency and Urgent Care, Medical Care and Maternity Services. The CQC also inspected the well led key questions for the Trust as a whole.

 

In November 2022, the CQC formally notified the Trust of their decision to impose conditions on its registration in relation to regulated activity for maternity and midwifery services. This was undertaken under section 31 of the Health and Social Care Act 2008.

 

The CQC report was published in June 2023 and included 95 ‘Must-Do’ and 45 ‘Should-Do’ actions. In response to the findings, the Trust submitted an improvement plan to the CQC which was approved on 20 July 2023.

 

The Trust reports on progress with the improvement plan at the monthly engagement meetings with the CQC. At the time of submitting this paper, the Trust has closed 61 of the 73 actions.

 

A monthly submission is made to the CQC providing an updated position on progress in addressing the issues highlighted in the Section 31 notice. The submission is due on the 23rd of each month. The monthly section 31 maternity submission was last made on 23rd August 2024.

 

This submission is reviewed, every month, by the Trusts Maternity Assurance Group which is a formal subcommittee of the Trust Quality Committee.

 

The CQC have been invited onsite to visit Maternity Services at York Hospital on 9 September 2024.

 

2.    Maternity and Neonatal Single Improvement Plan

 

In response to CQC inspection a rapid improvement plan was developed and key actions to address CQC concerns put in place. Progress against these actions are reported in the monthly section 31 maternity submission. The Trust recognised that the required improvements must extend beyond the scope of the CQC inspection if long-term sustained improvement is to be achieved. As a result, the Maternity and Neonatal Single Improvement Plan (MNSIP) was developed to also include the wider national maternity improvement agenda.

The Maternity and Neonatal Single Improvement Plan aligns with the National Three-Year Delivery Plan for Maternity and Neonatal Services (2023 – 2026). The plan has been developed with staff, service users and stakeholders following two engagement days held in November 2023 and April 2024. It also incorporates improvement areas identified through:

The Maternity and Neonatal Single Improvement Plan has four workstreams which align to the National Three-Year Delivery Plan for Maternity and Neonatal services (2023-2026). Each workstream has a Senior Responsible Owner who are members of the Senior Leadership Team for the Family Health Care Group. In addition, two members of the trust Programme Management team have been deployed to Maternity and Neonatal services to support delivery of the Maternity and Neonatal Single Improvement Plan.

Workstream

Senior Responsible Owner

Workstream 1: Listening to and working with Service Users and Families with Compassion

Sascha Wells-Munro OBE, Director of Midwifery and Miss Claire Oxby, Transformation Lead Obstetrician

Workstream 2: Growing, Retaining & Supporting our Workforce

Sascha Wells-Munro OBE, Director of Midwifery and Miss Claire Oxby, Transformation Lead Obstetrician

Workstream 3: Developing and Sustaining a Culture of Safety, Learning and Support

Dr Jo Mannion, Care Group Director

Workstream 4: Standards and Structures that underpin Safer, more Personalised and more Equitable Care

Gemma Ellison, Associate Chief Operating Officer, Family Health Care Group

To enable robust oversight and assurance on delivery of the Maternity and Neonatal Single Improvement Plan, the Maternity and Neonatal Single Improvement Plan Oversight Group meets monthly. Escalations are reported through the Maternity Assurance Group, co-chaired by the trust Medical Director and Chief Nurse and the Trust Programme Management Board, chaired by the Trust Deputy Chief Operating Officer.

3.    Key Improvements and progress against the Maternity and Neonatal Single Improvement Plan

Each of the four workstreams have high-level actions and milestone actions. The high-level actions are statements we want to achieve. The milestone actions are key events or actions which need to happen to support delivery of the high-level actions. See appendix 1 for an overview of the high-level actions.

There are 33 high-level actions and 204 milestone actions in the Maternity and Neonatal Single Improvement Plan. Since finalisation of the plan in March 2024, 2 high-level actions and 47 milestone actions have been completed.

Below are examples of some of the key improvements and actions completed to date:

·         Two engagement events have taken place with service users, staff and all key stakeholders to develop and review the Maternity and Neonatal Single Improvement Plan to ensure it is co-produced and is representative of the service needs.

·         New appointments to the Senior Leadership Team have taken place:

o   Sascha Wells-Munro OBE, Director of Midwifery

o   Gemma Ellison, Associate Chief Operating Officer

o   Mr Olujimi Jibodu (former) and Miss Claire Oxby (current), Transformation Lead Obstetrician

o   See appendix 2 for full senior leadership team structure.

·         Maternity and Neonatal Voices Partnership (MNVP) leads and volunteers are embedded and actively supporting pieces of improvement work. Recent appointments to the team include a dedicated neonatal lead and an engagement lead for Scarborough and East Coast areas. See appendix 3 for the MNVP leads structure.

·         The service has moved from a paper patient record system to an electronic patient record system (BadgerNet), and all women have access to their maternity records via the electronic system.

·         The service has moved from a paper ultrasound referral system to a digital referral and booking system in line with the rest of the trust, this provides greater oversight of scan capacity and allows scans to be booked in line with the Saving Babies Lives V3 recommendations.  

·         A Quality Improvement project for antenatal clinic has been completed and a new antenatal clinic template implemented, this means a consultant obstetrician is always available in clinic and will see their own women and birthing people on their caseload which provides consistency and continuity of care for women, birthing people, and families.

·         The nationally recognised Birmingham Specific Obstetric Triage System (BSOTS) has been implemented on both sites. The triage system supports women and birthing people being assessed within the first 15 minutes and care prioritised on the potential clinical risk identified. See appendix 4 for the BSOTS compliance graph.

·         The Midwifery workforce review and national workforce tool (birth rate plus) has been completed, both identifying a gap in workforce of 44 whole time equivalent midwives across the services.

·         A baseline review of current patient information provision related to language and easy read supporting inclusion and accessibility has been completed. There are now QR codes that enable women to access patient information and advice leaflets in the top 10 languages and coproduction of the Integrated Care Board Local Maternity and Neonatal System (ICB LMNS) easy read guides which are currently going through the internal governance process before publication. See appendix 5 for the QR codes poster supporting service users to access patient information and advice leaflets in the top 10 languages.

·         Work is underway to review the population and demographic data for the York and Scarborough geography which is being conducted with public health colleagues to better understand the needs of the population we serve. This is to ensure that the services we provide are equitable, inclusive and meet the needs of all women and birthing people, including our global majority.

·         Collaborative process and pathway mapping sessions with service users have been completed for key improvement areas:

o   Postnatal discharge - discharge video developed

o   Induction of Labour - under review in collaboration with the ICB LMNS and Advancing Quality Alliance (AQA)

o   Debrief Services - birth afterthoughts services are under review in collaboration with the ICB LMNS

o   Infant Feeding Services (ensuring equity of access to specialist services)

o   Elective C-Section (ensuring capacity meets demand)

o   Bereavement Services (full review of clinical care pathway in line with national best practice standards)

·         Weekly rapid Quality Improvement sessions ‘Hot Topics’ are embedded. The invite includes the entire maternity directorate and service users to co-produce improvement projects. All area’s identified for improvement are based on women’s and staff’s feedback and the standing agenda includes a patient story and reflection section  

·         A multidisciplinary team attend the Maternity and Neonatal Voice Partnership Quarterly Meetings

·         Patient information ward boards have been reviewed and co-produced with service users. See appendix 6 for the re-designed ward boards - antenatal clinic example.

·         A baseline review of all maternity and neonatal estates has been completed and a National maternity estates survey submitted to NHS England (April 2024)

·         The process for reviewing stillbirth and neonatal death using the national Perinatal Mortality Review Tool (PMRT) has been reviewed to ensure timeframes are adhered to and families are involved in the review as required by MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) and the Maternity Incentive Scheme (MIS)

·         A baseline assessment of nutrition and hydration provision has been completed.

·         The Culture SCORE Survey has been undertaken in collaboration with NHS England and the Perinatal Culture Leadership Programme

·         A thematic review of 49 Post-Partum Haemorrhage (PPH) cases has been undertaken which has informed the PPH Quality Improvement project with the aim of a sustained reduction of the PPH rate across the Trust. See appendix 7 for an overview of the Section 31 Quality and Safety metrics which includes PPH rates.

·         The Maternity and Neonatal Fundamentals of Management HR training package has been developed and launched for staff with line management responsibilities.

·         Following service user feedback refreshments and healthy snacks are now available whilst women and families wait in triage and outpatient areas.

·         Collaborate working with the health and safety team across the trust has taken place to improve all elements of health and safety and infection prevention requirements.

·         The latest MBRRACE-UK perinatal mortality report from 2022 reported that the York and Scarborough Teaching Hospitals NHS Foundation Trust perinatal mortality rate was 4.14 per 1000 total births, this rate is average when compared to similar sized hospitals.

 

 

4.    An overview of the key risks associated with delivery of safe maternity and neonatal services and the Maternity and Neonatal Single Improvement Plan

 

Below provides an overview of the key risks associated with delivery of safe maternity and neonatal services and the Maternity and Neonatal Single Improvement Plan

1.    A midwifery staffing gap has been identified following the midwifery workforce review. There is a risk that staff will not have capacity to continue to support developing and implementing the Maternity and Neonatal Single Improvement Plan because the priority focus of capacity of current staffing will be to deliver safe clinical services. This will result in high-level and milestone actions going off track and may result in some elements of the plan not being delivered. The prioritisation exercise which is currently underway will indicate where current staffing resource should focus and where staff external to the family health care group can support delivery of the actions. As a result, actions categorised as priority 2 and priority 3 may be required to complete a change request form to extend the timelines for delivery or change the scope of the project.

 

2.    There is a risk that the additional workforce reviews underway will result in gaps being identified in the other staffing establishments (Obstetrics, Neonatal, Operational and Admin establishments). Workforce reviews and recommendations are being conducted in line with national best practice standards and initial findings will be shared with the Senior Responsible Owners to escalate to the Trust Senior Leadership Team and agree appropriate action. 

 

3.    There is a risk that the Quality and Patient Safety Governance Framework cannot be embedded due to gaps identified in the midwifery and governance and safety team establishments. Testing of the framework has commenced, and multidisciplinary attendance at core maternity safety meetings is being monitored to assess the impact of this risk.

 

4.    Additional resource is required to support delivery of the Maternity and Neonatal Single Improvement Plan. There is a risk that the additional investment in staffing, estates and equipment required to provide safe care and adherence to national standards cannot be allocated in the current ICB funding arrangements. As a result, progress against current timelines will not be realised and some elements of the plan may not be delivered. An initial assessment of the Maternity and Neonatal Single Improvement Plan has taken place to further understand this risk to delivery and a second piece of work is currently underway to prioritise the high-level actions to identify where current resource should be focussed to contribute to mitigating this risk further. As a result, actions categorised as priority 2 and priority 3 may be required to complete a change request form to extend the timelines for delivery or change the scope of the project.

 

 

5.    Key actions to mitigate the identified risks to provide safe maternity and neonatal services and delivery of the Maternity and Neonatal Single Improvement Plan

 

A full Equality and Quality Impact Assessment (EQIA) has been undertaken that identifies the risks related to non-investment, the reduction in risk if investment is achieved and the mitigations in place to ensure safe delivery of services day to day.

Following completion of the EQIA and presentation to the trust board and Integrated Quality Improvement Group the following actions have been agreed:

·         To review the efficiencies for mandatory and statutory training across nursing and midwifery.

·         To review the overspend in maternity services for 2023/24.

·         To review the run rate for bank and agency staff usage in maternity for 2023/24.

·         To ensure all new specialist midwife roles recommended by NHSE are reviewed for a system-wide approach.

·         To update the corporate risk register for maternity service’s risks.

·         To add each element of the maternity and neonatal equality and quality impact assessment to the speciality risk register.

·         To review the provision of theatre scrub nurses for caesarean sections against recommended national best practice standards and scope opportunities for greater efficiency and effectiveness.

 

6.    Key actions in the Maternity and Neonatal Single Improvement Plan to be progressed in 2024/25

 

·         To complete the Maternity and Neonatal Single Improvement Plan prioritisation exercise in response to key risks

·         To develop the Maternity and Neonatal 1-3 year estates plan  

·         To develop the Maternity and Neonatal 1-3 year training plan

·         To complete a baseline review of all equipment on the asset register

·         To complete the workforce reviews for the Obstetric, Neonatal, Operational and Admin establishments

·         To develop the Maternity and Neonatal recruitment and retention strategy

·         To continue working with system partners (ICB LMNS) to review our debrief and induction of labour services

·         To implement the National Perinatal Pelvic Health Service in line with the National Service Specification

·         To work with Kornferry to produce an action plan to improve culture in the workplace following completion of the Culture SCORE Survey

·         To continue to review guidance and standard operating procedures in line with national recommendations

·         To conduct baby abduction drills on both sites to assess if the security improvement works have had the anticipated impact

·         To secure additional resource to increase scan capacity to meet Saving Babies Lives V3 recommendations

·         To develop and implement the transitional care service

 

7.    Recommendations

 

The North Yorkshire Overview and Scrutiny Committee are asked to note the approach and progress the Trust is making to respond to the issues identified by the Maternity CQC inspection.

 

8.    Appendices

 

Appendix 1: Overview of High-Level Actions in the Maternity and Neonatal Single Improvement Plan

Appendix 2: Senior Leadership Team Structure

Appendix 3: Maternity and Neonatal Voices Partnership (MNVP) leads structure

Appendix 4: Birmingham Specific Obstetric Triage System (BSOTS) compliance graph

 

Appendix 5: QR codes poster supporting service users to access patient information and advice leaflets in the top 10 languages.

 

Appendix 6: Re-designed patient information ward boards which have been co-produced with service users

 

Appendix 7: overview of the Quality and Safety metrics which includes Post-Partum Haemorrhage rates)