Agenda item

Purpose: To understand the causes of the maternity unit closures during August 2014 and the action that is being taken to avoid reoccurrence.

 

Gill Valentine (Director of Midwifery) and Caroline Ainslie (Director of Nursing), at Royal Berkshire NHS Foundation Trust, introduced the report to the Commission and provided Members with a presentation. Gill Valentine advised that the presentation was divided in two sections – the services provided by the maternity unit and the outcome from the Care Quality Commissioning report (March 2014).

 

Members were informed that the Royal Berkshire Hospital (RBH) provided maternity services for West Berkshire residents which included the provision of antenatal care, homebirth and postnatal care. Members were presented with activity statistics which helped to illustrate the number of deliveries and births year on year and the projected activity for 2014/15:

	2013/14	2014/15 year to date
Deliveries	5596	4288 (Projected - 5717)
Births	5689	4349 (Projected - 5798)

 

 

 

 

 

 

 

 

In most cases mothers could choose where to give birth and they typically chose to use hospitals in or around their local area. The following table illustrated the use of providers in the nearby area:

Year		Great Western  Hospital (Swindon)		Hampshire health  Trust (Basingstoke)		Oxfordshire University Hospital (John Radcliffe)	Royal Berkshire Foundation Trust	Other
12/13	Q1		20%		38%	1%	41%	0%
	Q2		17%		34%	5%	44%	0%
	Q3		16%		31%	9%	44%	0%
	Q4		17%		31%	7%	43%	2%
13/14	Q1		15%		36%	10%	37%	2%
	Q2		17%		35%	5%	43%	0%

 

Gill Valentine advised that RBH currently employed 183 full time equivalent midwives who provided a midwife to birth ratio of 1:32. Throughout 2014/15 the actual ratio at RBH had fluctuated between 1:31 – 1:36, the month on month fluctuation being caused by the number of births and staff in post. However, RBH achieved 1:1 care in 98%-100% of cases. Members were advised that that other providers reported care ratios of between 1:30 – 1:35. RBH had undergone a Birth-rate Plus Assessment to determine the maternity service level of staffing and skill mix. The results would be issued in January and would be followed by a recommended birth ratio based on the nature of cases.

 

RBH had reciprocal arrangements in place with neighbouring maternity service providers which enabled them to accept women from other units when support was required and similarly support could be requested by RBH. Diversions were only used when all other forms of escalation had been implemented. Gill Valentine explained that in August 2014 the fundamental reasons for diversions were predominantly midwifery staffing levels.

 

To alleviate the reliance on unit diversions RBH had taken the following actions:

 

·         Recruited into vacancies, 8.8 FTE current vacancies and expanded to 9.4 FTE, with the service aiming to recruit above the initial vacancy level in order to offset against staff leave.

·         Recruited permanent posts to cover staff maternity leave.

·         Used agency midwives on a semi-permanent basis to alleviate pressure.

·         Reviewed all the roles undertaken by midwives to ensure their specialist skills were put to best use.

·         Reduced the number of midwives on study leave at any one time to minimise the impact on staffing levels on the wards.

 

Gill Valentine highlighted the outcome from the Care Quality Commission (CQC) report from March 2014 which had in part promoted the topic for discussion. It concluded that:

 

·         The RBH offered a safe service with caring & committed staff.

·         There was a high midwife to birth ratio.

·         Caesarean section and induction rates were higher than average.

·         The ‘normal birth’ rate was lower than average and unchanged for 8 years.

·         The length of stay was higher than average.

·         They reported a higher number of unit diversions compared to other providers.

 

The CQC report concluded that there was a shortfall in meeting national standards for dedicated labour ward cover by Consultant Obstetricians. Furthermore, it concluded that the midwifery workforce was understaffed and recommended that a review took place to identify those tasks currently undertaken by midwifes but that could be carried out by others. The report also highlighted areas for improvement in the establishment’s facilities and amenities.

 

Gill Valentine advised the Commission that in response to the CQC’s finding the service had reviewed the tasks completed by midwifes. They concluded that, through the additional support of nursing staff, midwifes should be made available to complete tasks in accordance with their specialism. This was supported by the closure of two delivery beds in the Rushey ward and an increased number of midwifes recruited. Overall, the changes had allowed the reassignment of tasks to alterative medical staff in order to maximise midwife efficiency and availability.

 

Furthermore, RBH had appointed two locum obstetric consultants who were due to start in February for a period of 6 months and a business case for the posts to be made permanent had been agreed by the RBH Executive. In addition, a review of the middle grade tier was underway to look at further support. Overall, the changes sought to increase the number of ward hours during which medical support was available by 90 by the end of February 2015.

 

Gill Valentine explained that the service had focused on the culture changes which had been an area for improvement highlighted by the CQC report. She advised that patients had completed a safety questionnaire which had produced baseline analysis data. Also, an improvement project had been established to oversee the development of a culture assessment tool to assist ongoing monitoring. Gill Valentine stressed that senior staff were aware of the necessary culture changes and the possible effects on patient safety.

 

Councillor Brain Bedwell thanked Gill Valentine for the presentation and welcomed Members questions.

 

In response to points raised by Councillor Emma Webster, Gill Valentine advised that the geography of suites within the maternity ward had been recognised as an area for improvement but stressed that the current layout had not caused any health problems to date.  The service had longer term plans to improve the layout which included a refurbishment if funding was available.

 

The revised study leave arrangements would not impede the training and development of midwifery staff. The availability of training would remain the same but the number of staff accessing it at any one time would be reduced in order to reduce its impact on patients. The use of agency midwifes cost the service significantly more than directly employed staff but it was necessary to continue the support until the additional 9.4 FTE started.

 

Members asked whether training plans were in place to develop staff to Band 7 and therefore provide increased higher management cover on the ward. Gill Valentine advised that training started at band 5 and progression to band 6 took approximately 9 months. Development to band 7 was dependent on the individual’s leadership and management potential and therefore the timeframe was not the same in all cases. Gill Valentine advised that the unit had recruited the necessary number of band 7 staff required following the CQC findings.

 

Councillor Garth Simpson stated that the proposed consultant obstetrician’s hours were still lower than required and asked whether the ward hours were still a concern. Gill Valentine advised that they would continue to monitor the ward hours and plans were in place to encourage the increased availability of consultant obstetricians. The service proposed that doctors’ roles could offer the support required and suggested a review to look at extended cover and support. Members were informed that providers aspired to achieve 168 hours per week and reportedly that, nationally, only 2 establishments had achieved that target.

 

Councillor Simpson asked for clarification on the fundamental reasons why RBH had been required to divert mothers to alternative providers last year. Gill Valentine advised that RBH experienced staffing difficulties which in turn affected patient safety. She stressed that staffing was a national issue. Although applications had been received for vacant midwife posts it was a very specialised role which required a specific set of skills and knowledge. Gill Valentine advised that creative methods of recruitment had been introduced to address the ongoing demand for midwifes which had had a positive impact.

 

Councillor Roger Hunneman asked whether the NHS Foundation Trust had considered providing a maternity service at a local community hospital to alleviate demand on the RBH. Gill Valentine advised that the suggestion had been considered previously and it offered both solutions and challenges which would require further thought. She advised that resources were focused on improving the central service rather than breaking the service into smaller sections. Whilst the provider was not averse to the idea, Gill Valentine advised that the proposal was not an option at the present moment.

 

In response to questions raised by Councillor Alan Macro, Gill Valentine advised that although the CQC report stated that the rate of staff sickness was directly related to stress levels, in her opinion, this was debatable. Sickness levels were monitored constantly and support was available for staff when necessary. She acknowledged that staff sickness fluctuated month on month but this was not specifically related to stress. She reiterated to Members that midwifery was demanding and tiring but staff support was available.

 

Gill Valentine advised that the CQC report identified the need to review governance arrangements and the process for escalating issues. These had since been clarified.

 

Rachael Wardell asked for information about the connection between the maternity units and supporting services. Gill Valentine advised that the maternity services worked with commissioners of Perinatal Mental Health services to maximise accessibility. She advised that women could self-refer or be referred through the maternity unit – the feedback from service users had been very positive and indicated that a large proportion of users had been referred from the maternity unit which reinforced the well established links in place.

 

Members heard that the unit had a good working relationship with Health Visitors. Information was shared with Health Visitors for all expectant and new mothers and was accompanied by a discharge form and/or telephone call if necessary. Gil Valentine stated that the handover process worked well for families with more complex needs but suggested that the process did not always meet the needs for families with less complex needs.

 

Gill Valentine advised the Commission that the Poppy Team (community based, specialist midwives) offered scalable support dependent on the mother’s needs. Outcome data suggested that the service was working very well. The unit also had a strong links with social services which supported strong Child Protection practise.

 

Members heard that the availability of extended services through children’s centres had been reduced. Currently the main source of ongoing support was offered via Willows Edge.

 

Councillor Keith Woodhams stated that the CQC findings raised concern but, perhaps more alarmingly, the report suggested that some of the issues had only been addressed because the CQC inspection was announced. Members questioned the ventilation issue which had been highlighted by the CQC report. Gill Valentine acknowledged that the matter had taken some time to resolve and advised that the remedy required intense resource and the closure of rooms which would have an impact on capacity. The issue was being addressed.

 

Members asked about the coordinator role and diversion process. The Commission heard that a senior member of staff was tasked with the coordination of services, was  not therefore counted within the numbers of care staff assigned to the shift and played a pivotal role in the overall management of the wards. Gill Valentine said that the coordinator fulfilled their role 86%-96% of the time, with the remaining time being   used on the ward. Plans were in place to ensure the coordinator was available to fulfil their role 100% of the time. Members heard that the diversion policy was typically only in operation for between 2 and 30 hours on any occasion and was applied only to women who had been assessed as a lower risk. Gill Valentine advised that it was difficult to specify the frequency in which diversions were enacted. She stated that it was more often the case that women were diverted to other units rather than RBH receiving cases.

 

Councillor Dave Goff asked whether RBH was expected to answer the report findings or whether the actions would be followed up for as a matter of course by the CQC. Gill Valentine advised that a robust action plan was in place which was monitored by the Clinical Commissioning Group (CCG) and the service continued to meet quarterly with the CQC. However, these were existing meetings and did not focus solely on reviewing the action plan. Members heard that the CQC could return to RBH at any time to conduct their inspection and therefore the Trust took the report findings and delivery of the action plan very seriously. Furthermore, the Improvement Programme Board and Assurance Board had sight of the action plan and provided assurance that appropriate progress was being made.

 

Councillor Brian Bedwell asked whether the service planned to expand the training facilities to improve the rate and volume of trained midwifes. Gill Valentine advised that the feedback from staff was positive and they had no reason to believe the facilities required development; there were no plans at the current time to make any changes.

 

Councillor Bedwell thanked Gill Valentine and Caroline Ainslie for their time and support enabling Members to understand the situation in more detail.

 

Resolved that:

·         Councillors Bedwell, Hunneman and Webb would meet to identify possible recommendations for presentation and consideration at the Commission’s next meeting.