Bradford Royal Infirmary

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At this assessment the acute maternity service group (ASG) was rated good for safe in May 2024. Safety was a top priority that involves everyone, including staff as well as women and families using the service. There was a culture of safety and learning. Safety and continuity of care was a priority throughout women’s care journey with collaborative and a joined-up approach to safety. This included referrals, admissions, and discharges, and where women were moved between services. There was a strong awareness of the risks to women across their care journeys. The approach to identifying and managing these risks was proactive and effective. The service demonstrated improvements had been made with regard to the compliance for the recording of risk and access to interpretation services. There was a purpose built maternity theatre suite with a designated recovery area and 2 additional enhanced maternity care rooms. The maternity assessment clinic and day assessment unit were going to be relocated into a new area to improve patient flow and increase bed numbers. Improvements had been made with regard to the completion of equipment checks and robust processes were in place to ensure appropriate maintenance schedules. Staff received the support they needed to deliver safe care. This included appropriate training relevant to their role, supervision, appraisal, and support. Staff at all levels have opportunities to learn. In March and April 2024, we received a small number of staffing patient concerns regarding alleged unsafe staffing levels and delays to treatment. During the assessment we spoke to a large number of staff within Maternity services. None of these staff raised any patient safety concerns.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Safety was a top priority that involves people using the service. We spoke with several women, birthing partners and family relatives who confirmed they had no concerns regarding raising complaints with patient safety or staffing concerns. They felt part of the care planning process and were encouraged and supported to raise any concerns. We saw examples of "we said you did" on display boards on the M4 ward. The board showed evidence that staff had listened to patient feedback from “friends and family feedback” and had made appropriate changes to practices as a result.

Safety was a top priority that involved staff as well as people using the service. There was a culture of safety and learning. This was based on openness, transparency and learning from patient safety events. Staff we spoke with said that risks were not overlooked or ignored, and processes were in place to put things right, learn and improve. Senior leaders told us lessons learned were produced by the risk team and sent to every member of staff. Staff confirmed they received information on lessons learned from recent incidents in several ways such as a safety bulletin and weekly email updates. Staff said they could attend a weekly multidisciplinary team meeting and gave examples of learning and action taken. We were informed there was pastoral support for staff and staff could be signposted to additional psychological support following any traumatic cases. Lessons were learned from safety incidents or complaints which resulted in improvements. We heard several examples from staff who had changed practices surrounding culture and diversity given the demographic of the local population. For example, staff offered women the opportunity to remove their hijab and or headscarf during labour as a preferred choice. Women had the choice to choose male or female midwives to support their cultural beliefs. We saw posters on display suggesting differing birthing positions to improve the birthing experience.

Lessons were learned from safety incidents or complaints, resulting in changes that improved care for others. Senior leaders informed us there was a weekly safety event review forum. At this meeting they discussed investigations into patient safety events in order to learn and prevent reoccurrence. The meeting was multidisciplinary with midwifery, obstetric, neonatal, and anaesthetic staff attendance. Quoracy was observed for cases requiring neonatal and anaesthetic expertise. The acute service group (ASG) shared examples of agendas with the CQC to evidence that 4 differing incidents were scheduled at each meeting for discussion and learning. The meeting minutes were documented online on the incident reporting system and shared with the wider team via the weekly quality and safety bulletin. These were also shared with the wider health care partnership system. The ASG had plans to display governance boards to communicate current themes and trends in each area. Staff were able to explain the investigation process. We saw examples when incidents were reported and when learning had improved patient safety. There was a robust governance process in place where complaints, incidents and risk were reviewed identifying lessons learnt and action planning. Senior leaders told us there was a thrice weekly huddle where recent incidents were thematically reviewed by quality and safety midwives. Any learning and actions were cascaded to staff. Senior leaders shared a trust wide example of a recent digital improvement for the process of collecting friends and family feedback using a QR code. Senior leaders shared evidence of incident investigations which showed they had been appropriately investigated and reported. They followed process to report incidents to external partners such as Healthcare Safety Investigation Branch (HSIB) and Maternity and Newborn Safety Investigations (MNSI).

Care and support was planned and organised with women, together with partners and communities in ways that ensure continuity. The majority of women we spoke with confirmed they had a named midwife throughout their pregnancy and were able to contact them if required. All women were satisfied their dignity and privacy had been respected. Women provided positive feedback about having enough information to decide on their care and treatment decisions which included delivery locations and birthing plans. Women reported that staff asked about their emotional wellbeing at each antenatal and postnatal appointment. We spoke to 11 postnatal women from a range of different ethnic backgrounds. They confirmed they had no concerns about the care they received throughout labour and birth. We heard examples of how their pain was managed, and how they were kept informed, and that consent was always sought. Women’s positive feedback included "was in the best hands and felt calm and safe", "the midwife did a perfect job, she stayed throughout," and would "recommend to others." Women we spoke with were supported with the differing options to feed their baby and gave positive feedback for partner involvement throughout. Senior leaders told us the acute service group (ASG) were supportive of families within the community and had instigated several innovative initiatives. For example, staff offered a coat rail providing a supply of second hand coats for both children and families of women. The next planned initiative was to offer school uniforms. There was positive feedback from women and their families.

Safety and continuity of care was a priority throughout women's care journey with a collaborative, joined-up approach to safety. Staff were aware of guidance, pathways, and processes in relation to referrals, admissions, and discharge. For example, when women needed to be transferred to other regional tertiary centres for speciality scans / assessments or treatments. There was a strong awareness of the risks to women. Staff were able to identify and manage these risks using various risk assessments and tools in line with national guidance. Staff used cardiotocography (CTG) as a method of assessing fetal well-being. In addition, central monitoring is used enabling senior midwifery and obstetric staff to continually assess and monitor the wellbeing of women and identify risks of deterioration. Staff gave positive feedback for the recently adopted Birmingham symptom specific obstetric triage system (BSOTS) in the maternity assessment centre (MAC).

We received feedback from stakeholders and collaborative working was yet to be embedded.

Safety and continuity of care was a priority throughout women's care journey with a collaborative, joined-up approach to safety. This included referrals, admissions, and discharge, and where women are moved between services. There was a strong awareness of the risks to women across their care journeys. Care and support was planned and organised. The processes to identify and manage these risks were proactive and effective. Senior leaders told us they held monthly joint multidisciplinary (MDT) meetings with a regional tertiary centre to discuss any joint cases. We reviewed completed risk assessments which demonstrated the acute service group (ASG) had improved their compliance for the recording of risk Senior leaders told us the induction of labour was part of a quality improvement project in combination with elective planned admissions. They described clear processes of how they worked to plan for induction of labour. There was a daily call within the local maternity system (regionally) to discuss the number of labouring women and their associated acuity and risks and planned their admissions at the most appropriate unit. Staff reported positive feedback on the use of the balloon catheters for induction of labour and work was ongoing to ensure all midwives were trained accordingly. The frequency and number of induction of labour were discussed at a daily meeting and were reported nationally. We observed staff telephoning and risk assessing women who were at home waiting for their planned induction of labour. The ASG had improved access to interpretation services to ensure women felt safe and understood. We saw the use of language line carts being used in addition to face to face, telephone and video translation services and the use of bilingual staff. In addition, the service had developed multiple leaflets and signage in differing languages which reflected the languages in the local population.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We spoke with 22 women who gave a positive response when asked about the cleanliness of the units and no concerns were raised. We heard that some areas were cleaned every 2 hours. We spoke with 27 women and all women confirmed their emotional wellbeing had been checked at each antenatal and postnatal appointment. We reviewed the national maternity services survey 2023 which showed the trust scored; • 8.9 out of 10 for women being told who to contact if they had any mental health concerns following a birth • 7.6 out of 10 for women being provided with relevant information about feeding their baby. These scores were two of the best overall scores when compared nationally.

Senior leaders informed us that daily safety huddles incorporated discussions about the potential risks of birthing women. All staff we spoke were able to provide the top risks for the service. For example, staffing numbers (planned versus actual), theatre floors (infection, prevention, and control concerns), delays in induction in terms of volume of women waiting. Senior leaders could clearly articulate the mitigating plans to address each of these risk. The service identified there was a need for additional midwives needed for wellbeing checks whilst women were waiting to be admitted for induction of labour. Managers had mitigated this risk by offering shorter 4 hour shifts to bank staff on M3 or offered shifts to specialist midwives. This meant there was no impact to staffing from other units.

The acute service group (ASG) had improved their compliance of staff completing and updating risk assessments. Staff now used a digital platform for the recording of maternal early warning scores (MEW’s) and fresh eyes. The ASG had introduced a telephone triage assessment which was in line with Birmingham symptom specific obstetric triage system (BSOTS). This had improved the compliance of triaging women within 15 minutes. The ASG had a maternity dashboard to monitor clinical performance and governance. The ASG had procedures in place for the abduction of a baby. Managers had completed a recent abduction scenario and there was an embedded process for actions taken following a suspected abduction. In the event of an abduction staff sounded an alarm which would automatically lock down all exit doors and they followed a process to check women and babies on the ward. The ASG did not always accurately record and manage the recording of risk. We reviewed evidence from the National Reporting and Learning System (NRLS) and some incidents had been inaccurately recorded as low or no harm. Senior leaders told us staff were not always grading these correctly and acknowledged there was a gap in staff awareness and training had been scheduled. There was now a process in place so that all incidents were reviewed daily.

We spoke with 22 women who gave a positive response when asked about the cleanliness of the units and no concerns were raised. We heard that some areas were cleaned every 2 hours. There was a dedicated quiet room available on wards and units for women and families to have “time out” from the clinical area.

Senior leaders and staff confirmed there was a planned phased relocation into a brand new purpose built facility incorporating maternity assessment clinic and day assessment unit. There were two phases to this. The first phase was due to be completed in September 2024 with a second phase being completed in October 2024. The MAC unit would increase bed capacity from 4 to 6 beds. The day assessment unit would increase bed capacity from 4 beds to 5 beds following completion. During the second day of our assessment staff, we spoke to informed us that the midwifery led (low risk) birthing centre had been closed. Senior leaders informed us that the unit was not closed to admissions. They said staffing would be relocated from different areas to accommodate any new admissions / birthing women. Senior leaders acknowledged there was a misunderstanding with staffing concerning the words used when the unit was closed in this way.

Women were cared for in safe environments designed to meet their needs. Facilities and equipment were well-maintained and consistently supported staff to deliver safe and effective care. There was an appropriate number of cardiotocography (CTG) machines available. We observed a brand new purpose built theatre area. This included 2 new HDU enhanced maternal care (EMC) rooms with a dividing window, so midwives had clear oversight of both rooms. There was also a designated recovery area. We observed a purpose built waiting area which was next to the theatres for families and relatives. We observed multiple rooms where birthing pools were available. Equipment used to deliver care and treatment was suitable for the intended purpose. Most equipment was stored securely and appropriately. We observed staff carried out daily safety checks of specialist equipment. All equipment inspected was PAT tested and within date. However, we observed that the corridor leading from the maternity assessment unit to the labour unit was not clear of all obstructions as there were a number of metal cages used for the delivery of external purchases and internal in house deliveries. This was a risk as speedy access was required for emergency access to the labour unit. We escalated this with senior leaders who told us this corridor had been risk assessed following the last inspection in 2023. They gave assurances that staff were aware of the need to keep the corridors free of clutter and matrons completed regular checks. In addition, we observed the following areas of concern on the birthing unit. We saw boxes stored directly on the floor in the storage room. We found control of substances hazardous to health (COSHH) items in the kitchen cupboard unlocked in the dirty utility room. This was a risk as hazardous stock items were not stored in line with guidance and were readily accessible to members of the public.

At the last inspection the service was told they should improve completion of equipment checks in line with trust policies and appropriate maintenance schedules. At this assessment there was a robust procedure and effective arrangements to monitor the safety and upkeep of the premises. We saw evidence that all equipment inspected was PAT tested and within date. The emergency call bell was tested daily and could be heard in all areas.

Most women we spoke with said they had no concerns about staffing levels.

Senior leaders confirmed that registered and non-registered nurse staffing did not always meet the planned versus actual planned staffing levels. This was mostly due to vacancies, maternity leave, and sickness. This meant they did not always have enough staff with the right skill mix and experience to make sure women received consistently safe and good quality care. Senior leaders confirmed that there were medical gaps in the junior medical roster. This meant there were delays in medical reviews of women. Medical staff said they often missed breaks due to the acuity and numbers of women. In addition, there was a lot of exception reporting when they had worked longer than their expected shift time. Staff reported they received the support they needed to deliver safe care. Senior leaders had good oversight of mandatory and specific core competency training completion. Staff at all levels reported they had opportunities to learn and develop specific skills. they confirmed they had yearly appraisals by their ward managers. Managers confirmed their appraisal rates for their areas was 100%. Middle grade medical staff reported having good consultant supervision, especially when there was a serious incident or involvement with the maternity neonatal system investigation (MNSI). In April 2024 before the assessment a small number of staff escalated concerns with CQC regarding unsafe staffing levels. At times they reported feeling overwhelmed with workloads. We heard from staff that more specialist staff were needed following a birth rate plus assessment recent, however the results were not available to us at the time of this assessment.

There were appropriate staffing levels and skill mix to make sure people receive consistently safe, good quality care that meets their needs. Staff received training appropriate and relevant to their role. We observed Practical Obstetric Multi-Professional Training (PROMPT) scenario training.

We reviewed three months of staffing information which confirmed that registered and non-registered nurse staffing did not always meet the planned versus actual planned staffing levels. This meant they did not always have enough staff with the right skills mix and experience to make sure people receive consistently safe and good quality care that meets their needs. There was an escalation process to manage staffing risks. For example, senior leaders offered shifts to bank staff, redeployed staff if necessary and were able to escalate staffing issues to matrons. From Monday to Friday 8am to 5pm band 7 staff rotated as "hot desk" bed manager once a month and visited each area to review and manage any short falls in staffing. There was a process in place to manage oversight of all grades of staff. Senior leaders rostered both medical, registered, and non-registered midwives on the same rota. This was to ensure a safe skill mix for each shift. The service was actively recruiting staff which included newly qualified staff and international midwives. The service had recently completed a birth rate plus assessment. We heard from staff that more specialist staff were needed; however, the results were not available to us at the time of this assessment. We reviewed mandatory and core specific competency training records which showed the majority of staff were compliant within the agreed trust target. The professional development midwife and consultant rostered training dates for each member of staff. Staff informed us these included scenario based and case study training especially relating to high acuity situations. There was a clear appraisal process.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

Women told us they felt well cared for and informed about their medicines. They told us their pain relief was managed well. Women told us they felt well cared for and were informed about their medicines. They told us that they did not always get timely access to a doctor when requested across the units. They told us this could lead to delays in prescriptions being written. Women told us they could access pain and sickness relief. One woman said ,”the midwives are great – they always sorted out my pain relief quickly”. The acute service group (ASG) had access to translation services. The ASG was in the process of creating an online webpage with information for patients in the form of leaflets and videos. Although there was a process for women to administer their own medicines, they told us that their medicines were managed by the midwives when on the wards. Staff told us self-administration was rarely used.

Staff told us they were supported by ward leaders. Staff told us they received mandatory medicine management training and regularly updated it as well as training on relevant topics such as identifying sepsis. The service was currently up to date with medicines management training and safe administration of medicines training. They had access to electronic tools to support them. Staff told us they could request pharmacy support when needed and told us they would respond in a timely manner. However, they told us they regularly faced delays in accessing prescriptions for patients. This led to delays to women’s discharge which impacted the wards ability to safely care for patients. This was a trust wide issue and will be referenced in the well led assessment report. Staff described how they would report incidents. They told us they received feedback from incidents and learning through multiple channels including staff huddles, email bulletins and social media. However, we were not always assured this was done in a timely way.

Not all areas stored medicines in line with national guidance. On the labour ward, doors to areas where medicines were stored were propped open to reduce the temperature of the room. This is not in line with national guidance. The service did not monitor temperatures of rooms where medicines were stored. This was raised as a concern at the last inspection with a breach in regulation 12 safe storage of medicines. Whilst the service had addressed some concerns surrounding the safe storage of medicines in the post inspection action plan they had not addressed concerns surrounding room temperature checks and assurance. We did not see evidence of acknowledgement, mitigation or risk assessment of the risk of medicines being stored outside their recommended storage conditions.

The service did not always manage medicines or prescription stationary in line with national guidance. There were often delays in discharges due to delays in getting prescriptions filled by pharmacy. The acute service group (ASG) had a process for the supply of medicines via FP10 prescriptions, prepared to take out medicines (TTOs) and patient group directions (PGDs). However, these were not always managed well. Not all PGDs were in date and so had been reviewed as per the services policy. There were regular delays in accessing medicines from pharmacy for women on discharge. This had an impact on the wards discharging women in a timely manner. Not all FP10 prescription pads were stored in line with national guidance. Staff could not describe how they would identify if any prescriptions were missing. The ASG did not always manage controlled drugs well. Not all CD registers were in good condition and entries were not always legible. These concerns were a trust wide issue and will be referenced in the well led assessment report. The ASG had made improvements on the labour ward for the management of controlled drugs. The ASG had a process for reporting incidents, but staff did not always follow this. Incidents were not always reported in a timely way which led to a delay in learning and actions being implemented. For example, a controlled drug discrepancy that occurred in February 2024 was not reported until April 2024. The ASG introduced stricter measures as a result of these discrepancies. Staff told us that the new processes had impacted their ability to give care in a timely way. There was a process for ordering stock medicines from the pharmacy. Staff told us that that stock orders generally arrived promptly. The ASG recently conducted a programme of medicine management audits. The service had made improvements such as documentation of supply of to pre-labelled medicines on the wards.