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The Care Quality Commission (CQC) has recently told NHS maternity services in England to improve faster ‘to ensure that women and babies get consistently good, safe care’. In its March 2020 report, ‘Getting safer faster: key areas for improvement in maternity services’, the CQC found that 38% of maternity units in England are rated as ‘needing improvement’ for safety.
We are five years on from the Kirkup report which called for urgent improvements in maternity safety after the maternity scandal at Morecambe Bay, but the CQC found that the same issues are affecting maternity safety today. Adding its own recommendations to those made by Each Baby Counts, MBRRACE and other maternity safety initiatives, the CQC says that NHS maternity services are simply not improving safety fast enough.
What is the CQC?
The Care Quality Commission, also known as the CQC, is an independent regulator of health and adult social care services in England. By registering, inspecting, rating and reporting on health and social care services, CQC aims to encourage those services to improve for the protection of the public. CQC’s March 2020 maternity safety report was based on information it obtained from its own maternity inspections, the 2019 CQC maternity survey and talking to healthcare providers and members of the public.
What does the CQC’s 2020 report say about maternity safety?
The CQC’s report, Getting safer faster: key areas for improvement in maternity services, compared its ratings of maternity units in 2020 with its findings from its hospitals inspection in 2017.
In 2017, half of all maternity services were rated as inadequate or needing improvement for safety. The factors which affected maternity safety included:
- increasing numbers of high risk, complex pregnancies;
- a national shortage of midwives and obstetricians;
- the culture and leadership of some maternity services;
- poor multidisciplinary team working between different types of maternity staff (e.g midwives, obstetricians, neonatologists);
- failure to review and learn from adverse maternity safety events.
Today, in 2020, nearly 38% of maternity units are still CQC rated as ‘needing improvement’ for safety. Statistically, this is an improvement, but when we look more closely we see that it means that 76 maternity units in England still need to get better at providing safe care for women having babies.
What improvements in maternity safety are needed?
The CQC found that despite the slight increase in numbers of maternity units rated ‘good’ for safety, the problems identified by the 2015 Kirkup report are still affecting the safety of maternity care today. These include:
- maternity staff not having the right skills or knowledge;
- poor working relationships between different maternity staff, e.g. obstetricians, midwives and neonatologists;
- poor risk assessments;
- failing to investigate and learn from when things go wrong.
Since the Kirkup report further initiatives, such as the RCOG’s Each Baby Counts programme, MBRRACE and the CQC’s 2018 report, Opening the Door to Change, have reiterated the importance of urgent improvement in these key areas, for the safety of maternity patients.
What maternity safety improvements did the CQC’s 2020 report recommend?
The CQC called for change at three levels to increase the safety of maternity care:
- leadership - including risk management and culture;
- staff level - including staff competencies, teamworking and training;
- engagement with those who use maternity care.
CQC recommended maternity safety improvements in leadership
The CQC’s recommendations for improving leadership of maternity services included NHS trust boards and leadership teams making sure that maternity services have staff:
- with the required knowledge and skills,
- who work effectively as multidisciplinary teams; and therefore
- who can recognise and act fast to change the risk category of a pregnancy in response to an emergency situation or when a patient’s condition is deteriorating.
To achieve this, leaders of maternity services must:
- ensure that there are strong risk management processes in place;
- be accessible (if they work at service level to provide patient care, eg consultants);
- promote an inclusive culture where staff feel able to raise concerns and suggest improvements.
The CQC found that the maternity units with the best safety ratings had good leadership, policies and risk management at every level, and this encouraged openness, effective incident reporting, investigations and learning. Maternity services which prioritised learning were better at ensuring that staff had the correct skills, knowledge and experience to do their job, and they supported staff in developing and maintaining their professional skills and experience.
Outstanding maternity units had a culture in which reporting was valued and encouraged, with feedback and shared learning from investigations. In these units, staff were trained in recognising and reporting patient safety incidents. There was good communication between frontline staff and senior leaders, and effective audit and risk management processes were in place.
Maternity services with poor leadership did not monitor failures in teamworking, staff training competences, or properly manage serious incident investigations. These failings put patient safety at risk.
CQC recommended maternity safety improvements in staff competencies, teamworking and training
The CQC stressed the importance of maternity teams being able to work together well, being properly trained and having the knowledge and skills necessary to recognise and respond to an emergency. They found that maternity training still varies widely. If women are to receive safe maternity care including recognition and response to complications which change their risk status, training must improve in:
- core competencies (skills) of individual staff members;
- effective teamworking between different staff groups;
- scenario training for serious complications which need an effective multidisciplinary team response.
The CQC reiterated the importance of regularly updated training in fetal heart monitoring taking place in a multidisciplinary setting, including team working and situational awareness as well as use of equipment.
CQC recommended better engagement with women using maternity services
The CQC also recommended that maternity services engage actively with their patients, to learn from their experiences. Areas of concern amongst women surveyed included midwives not being aware of their medical history, which is of vital importance for risk management.
Safe maternity care is not an ambitious or unrealistic goal
The CQC’s recent report points to improved numbers of maternity units rated ‘good’ for patient safety, however, the number of maternity services still failing to provide consistent levels of safe maternity care remains an urgent cause for concern.
Countless reports in the last five years have come to the same conclusion about what’s wrong and what needs to be done. It’s about leadership, open culture, risk management, teamwork, training and commitment to patient care.
The CQC has stated that “Safe maternity care is not an ambitious or unrealistic goal. It should be the minimum expectation for women and babies.” Improvements in some NHS trusts have shown that it can be done. Now it needs to happen faster.
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