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This report describes our judgement of the quality of care at this hospital. It is based on a combination of what we foundwhen we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, thepublic and other organisations.

Ratings

Overall rating for this hospital Good –––

Maternity and gynaecology Good –––

Shrewsbury and Telford Hospital NHS Trust

OswestrOswestryy MatMaternityernity UnitUnitQuality Report

Robert Jones & Agnes Hunt HospitalGobowenOswestryShropshireSY10 7AGTel: 01691 404000Website: www.sath.nhs.uk

Date of inspection visit: 1 November 2016Date of publication: 16/08/2017

1 Oswestry Maternity Unit Quality Report 16/08/2017

Letter from the Chief Inspector of Hospitals

We inspected Oswestry Midwife Led Unit as part of a focused inspection of Shrewsbury and Telford Hospital NHS Trustin November and December 2016. We visited the unit unannounced on 1 November 2016.

We rated Oswestry Midwife Led Unit as good overall.

• Staff fully understood their professional responsibility to report incidents and concerns. No serious incidents hadbeen reported between 01 November 2015 and 31 October 2016

• Patient records were stored securely and we saw they were up to date and legible.

• Care and treatment is delivered in line the current evidence based guidelines. Staff adhered to the trustIntrapartum Care on a MLU or Homebirth policy (June 2016), all trust wide policies and procedures were availableto staff on the intranet.

• Effective systems of communication were established between the consultant led unit and the MLU, ensuring thateffective care and treatment could be delivered.

• Women told us that they felt very well cared for and the staff were caring, thoughtful and compassionate

• A full review of the maternity service was ongoing, looking at different ways to improve the service with models ofcare being scoped by the trust

• Midwives were clear about their role and levels of accountability

Professor Sir Mike RichardsChief Inspector of Hospitals

Summary of findings


Our judgements about each of the main services

Service Rating Why have we given this rating?Maternityandgynaecology

Good ––– Staff understood their responsibility to report incidentsand concerns. No serious incidents had been reportedbetween 01 November 2015 and 31 October 2016Patient records were stored securely and we saw theywere up to date and legible. Care and treatment isdelivered in line the current evidence based guidelines.Staff adhered to the trust Intrapartum Care on a MLU orHomebirth policy (June 2016), all trust wide policies andprocedures were available to staff on the intranet.Effective systems of communication were establishedbetween the consultant led unit and the MLU, ensuringthat effective care and treatment could be delivered.Women told us that they felt very well cared for and thestaff were caring, thoughtful and compassionate.A full review of the maternity service was ongoing,looking at different ways to improve the service withmodels of care being scoped by the trust. Midwives wereclear about their role and levels of accountability.We found urine sample bottles were stored in publictoilet, this did not reflect safe practice. When we broughtthis to the attention of the manager the bottles wereremoved immediately along with urine testing stripsand disposable receivers.

Summaryoffindings

Summary of findings


OswestrOswestryy MatMaternityernity UnitUnitDetailed findings

Services we looked atMaternity and gynaecology


Contents

PageDetailed findings from this inspectionBackground to Oswestry Maternity Unit 5

Our inspection team 5

How we carried out this inspection 5

Facts and data about Oswestry Maternity Unit 6

Our ratings for this hospital 6

Background to Oswestry Maternity Unit

The Shrewsbury and Telford Hospital NHS Trust is themain provider of district general hospital services fornearly half a million people in Shropshire, Telford andWrekin, and mid Wales. Ninety per cent of the areacovered by the trust is rural.

Deprivation is higher than average for the area, but varies(180 out of 326 local authorities for Shropshire and 96 outof 326 local authorities for Telford and Wrekin); 6,755children live in poverty in Shropshire and 8,615 in Telfordand Wrekin. Life expectancy for both men and women ishigher than the England average in Shropshire but lowerin Telford and Wrekin.

The maternity unit is part of the Royal ShrewsburyHospital NHS Trust based within the Robert Jones andAgnes Hunt Orthopaedic Hospital, Gobowen; a low-riskunit offers labour, delivery and postnatal care in a smallhomely environment.

The midwifery-led unit (MLU) at Oswestry had 163admissions with 62 deliveries between 01 November 2015and 31 October 2016.

We inspected this unit as part of our unannouncedmidwifery service inspection.

Our inspection team

Our inspection team was led by:

Inspection Manager: Debbie Widdowson, Care QualityCommission

The team included a CQC inspector.

How we carried out this inspection

To get to the heart of patients’ experiences of care, wealways ask the following five questions of every serviceand provider:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well led?

We carried out an unannounced inspection visit on 01November 2016. We talked with patients and women onthe ward. We observed how women were cared for andreviewed patients’ records of personal care andtreatment.

Detailed findings


This was a focused inspection, following up ourinspection from 2014. The unit was rated as good in alldomains.

Facts and data about Oswestry Maternity Unit

The MLU at Oswestry had 163 admissions between 01November 2015 and 31 October 2016 with the average

length of stay 1.99 days. In the same time period therewas 39 transfers out to The Princess Royal consultant ledunit; the main reason for transfer were recorded as delaysin labour and fetal concerns.

Our ratings for this hospital

Our ratings for this hospital are:

Safe Effective Caring Responsive Well-led Overall

Maternity andgynaecology Good Good Good Good Good Good

Overall N/A N/A N/A N/A N/A Good

Detailed findings


Safe Good –––

Effective Good –––

Caring Good –––

Responsive Good –––

Well-led Good –––

Overall Good –––

Information about the serviceThe Oswestry midwifery-led unit (MLU) is based within thegrounds of Robert Jones and Agnes Hunt NHS Trust. Theunit has two labour rooms, one with a pool, and a five-bedbay for antenatal and postnatal care. Shared toilet andshower facilities were available for women during theirstay.

The unit offers a friendly 'home-from-home' atmospherewith an emphasis on natural birth The MLU admits womenwho have been assessed as low risk and suitable to delivertheir baby there, as there are no medical facilities. Womenwho book and attend to deliver their baby in the MLUwould be transferred to the consultant led unit at PrincessRoyal Hospital, 34 miles away during labour whencomplications arose. Between November 2015 andOctober 2016 there were 163 admissions and 62 births inthe unit and 275 births within the community midwife area.

The MLU also cares for women who have delivered at theconsultant led-unit based at the Princess Royal Hospital(PRH) when they needed extra support with such things asbreastfeeding.

The unit is staffed by a team of midwives and womenservices assistants (WSA), who also offer a communitymidwifery service to the local area. We did not specificallyinspect the community midwifery service during thisinspection. One midwife, with a WSA was on duty duringthe day. A community midwife, who worked 7.5 hours each

day, supported the unit as necessary. Outside these hours,one midwife was on duty with support of a WSA; a secondmidwife was on call to support with deliveries as the needarose. The unit manager worked office hours.

GP clinics were held at the unit each day. A midwifesonographer held a clinic in the unit weekly and aconsultant held a clinic at the unit every other week. On theday of the inspection, there were three women and threebabies in the unit. We spoke with five members of staff, twowomen and we reviewed two sets of patient notes.

Maternityandgynaecology

Maternity and gynaecology


Summary of findingsWe rated this service as good because:

• Staff understood their responsibility to reportincidents and concerns. No serious incidents hadbeen reported between 01 November 2015 and 31October 2016

• Patient records were stored securely and we sawthey were up to date and legible.

• Care and treatment is delivered in line the currentevidence based guidelines. Staff adhered to the trustIntrapartum Care on a MLU or Homebirth policy(June 2016), all trust wide policies and procedureswere available to staff on the intranet.

• Effective systems of communication wereestablished between the consultant led unit and theMLU, ensuring that effective care and treatmentcould be delivered.

• Women told us that they felt very well cared for andthe staff were caring, thoughtful and compassionate

• A full review of the maternity service was ongoing,looking at different ways to improve the service withmodels of care being scoped by the trust

• Midwives were clear about their role and levels ofaccountability

However:

• We found urine sample bottles were stored in publictoilet, this did not reflect safe practice. When webrought this to the attention of the manager thebottles were removed immediately along with urinetesting strips and disposable receivers.

• The trust chose not to use the maternity specificsafety thermometer to measure compliance withsafe quality care.

Are maternity and gynaecology servicessafe?

Good –––

We rated safe as good because:

• Staff understood their responsibility to report incidentsand concerns. No serious incidents had been reportedbetween 01 November 2015 and 31 October 2016.

• Systems were in place to minimise the likelihood ofinfection and we observed that Oswestry MLU appearedvisibly clean in all areas we inspected.

• Medicines were managed safely; controlled drugs werechecked and signed as correct at the beginning of eachshift.

• Patient records were stored securely and we saw theywere up to date and legible.

• All staff had received safeguarding training and therewere systems in place to ensure prompt referral ofsafeguarding concerns were made.

• Formal handovers took place at the beginning and endof each 12 hour shift. Women’s care was discussed andtheir plan was reviewed.

However:

• We found urine sample bottles were stored in publictoilet, this did not reflect safe practice. When we broughtthis to the attention of the manager the bottles wereremoved immediately along with urine testing stripsand disposable receivers.

• The trust chose not to use the maternity specific safetythermometer to measure compliance with safe qualitycare.

Incidents

• Staff fully understood their professional responsibility toreport incidents and concerns and were encouraged bymanagers to do so. Staff were knowledgeable aboutwhat constituted a serious incident and they were ableto describe the types of situations they would expect toreport. Staff told us that incidents and complaints werediscussed and reflected at ward meetings through the‘quality and safety report’; this ensured the informationwas reached all staff to ensure lessons were learnt.

• Maternal transfers are not recorded as an incident bythe trust. They informed us this was because there is no




NRLS code to support this type of incident. However,there were 39 women transferred to the consultant ledunit between 1 November 2015 and 31 October 2016. Ifthe service is not reporting all transfers as incidents anopportunity to learn from these events may be missed.

• Incidents were reported by staff through the trust’selectronic process and feedback was received from themanager. There was also a “tick box” for staff tocomplete on the electronic form to request feedback.We were told that incidents and complaints werediscussed at monthly ward meetings through the‘quality and safety report’; this ensured the informationwas disseminated to all areas and to promote cross unitlearning. Midwives were able to describe incidents thathad occurred within the service.

• No serious incidents had been reported between 01January 2015 and 31 December 2016. There were 37incidents reported. Twenty six no harm incidents andnine low harm incidents reported during this timescale.

• There were no ‘never events’ reported by the MLUbetween 01 November 2015 and 31 October 2016. Neverevents are serious patient safety incidents that shouldnot happen if healthcare providers follow nationalguidance on how to prevent them. Each never eventtype has the potential to cause serious patient harm ordeath but neither need have happened for an incidentto be a never event

• There was evidence that staff from the MLU did notattend the monthly perinatal mortality meeting.However, the manager received the minutes and sharedthe information with the staff.

Duty of Candour

• The duty of candour is a regulatory duty that relates toopenness and transparency and requires providers ofhealth and social care services to notify patients (orother relevant persons) of certain ‘notifiable safetyincidents’ and provide reasonable support to thatperson

• Staff we spoke with described their obligations underduty of candour (DoC) and were aware of when theywould be required to act upon this. They had notparticipated in specific training that focussed on this buttold us they had received information and could findfurther guidance. There had been no incidents, whichrequired doc investigation.

• We heard examples whereby the trust had supportedmidwives being open and transparent through the Dutyof Candour process and a ‘no blame’ culture.

Maternity safety thermometer

• The Royal College of Obstetricians and Gynaecologists(RCOG) launched the maternity safety thermometer inOctober 2014. The maternity safety thermometermeasures harm from perineal (area between the vaginaand anus) and/or abdominal trauma, post-partumhaemorrhage, infection, separation from baby andpsychological wellbeing.

• The trust did not utilise the maternity-specific survey.The head of midwifery told us they were aware of thematernity specific thermometer but that they felt thatthe service collected the same information elsewhere.We reviewed data that the trust collected and foundthat the trust collected some data via the maternitydashboard however, they did not collect and reviewharm in relation to postpartum haemorrhage,separation of mother and baby and psychologicalwellbeing.

• The service submitted data to the national NHS SafetyThermometer patient care survey instead. Thismeasures harm from pressure ulcers, falls, urineinfections (in patients with a catheter) and venousthromboembolism.

Cleanliness, infection control and hygiene

• We observed that Oswestry MLU appeared visibly cleanin all areas we inspected. Cleaning schedules weresigned and appropriate equipment was in place such asfoot operated bins.

• We observed all staff complying with the trust infectioncontrol policy. We saw staff regularly washed theirhands and used hand gel. The hospital’s ‘bare below theelbow’ policy was adhered to. The October 2016 handhygiene audit report showed 100% compliance hadbeen achieved.

• There had been no reported cases ofMethicillin-resistant Staphylococcus aureus (MRSA) orMethicillin-sensitive staphylococcus aureus (MSSA)bacteraemia 01 November 2015 and 31 October 2016.

• Infection control guidelines, protocols and procedureswere readily available on the intranet.

• We reviewed the birth pool and found this to be wellmaintained with a daily signed cleaning schedule. Staffwere knowledgeable of the procedure to clean the birth




pool and the contradictions for use. Water samples weretaken from the pool as per the Legionella policy and thewater system was run twice a week. Thermometers wereused for water temperature testing prior to the womenentering the pool and a thermometer remained in thepool during use.

Environment and equipment

• The staff told us that they had sufficient equipment toconfirm the health and well-being of mothers andbabies. We saw that equipment was suitably maintainedand regularly tested. In the event of equipment beingfaulty, it was replaced or repaired promptly by theestates team.

• The resuscitation equipment, including a resuscitaire forbabies was accessible in an emergency situation. Signedrecords demonstrated that the equipment was checkeddaily and portable appliance testing was in date.

• Store cupboards were locked and found to be clean andtidy, when opened.

• A new-born transfer pod was stored on the ward. Thiswas checked and signed as in order daily by thewomen’s service assistant (WSA).

• The Ultrasonography midwife explained the process forservicing and testing the scanner. A call bell wasavailable in the scanning room should the need to alertother staff be necessary.

• The homebirth equipment carried by communitymidwives was checked and re stocked on the unit aftereach home birth or every Sunday. Community bagswere currently part of an audit to standardise theequipment bag.

• Fetal heart monitors and blood pressure cuffs werecleaned and checked after each use.

• In the waiting area public toilet, we found urine samplebottles and swabs stored on a radiator. Some urinespecimen bottles contained boric acid preservative.Boric acid helps to maintain the microbiological qualityof the specimen during transport to the laboratory.Although boric acid is only poisonous if taken internallyor inhaled in large quantities, its storage in this locationwas a risk as it was accessible to children. These itemswere removed immediately along with urine testingstrips and disposable receivers.

Medicines

• We observed that all medication was storedappropriately on the unit.

• One medication refrigerator had recently been underinvestigation and the contents destroyed due tovariances in the temperatures being recorded. Theestates department were currently running tests on theitem to establish whether it was for repair orreplacement.

• The staff we spoke with told us that there were no issuesin obtaining pain relief during labour.

• A medication audit carried out in October 2016 showedthe unit was compliant with good practice guidelines.Three issues were identified which related to roomthermometer calibration, the pin code key lock tomedication room had not been changed recently andintravenous fluids were found on a birthing room trolley.All these issues had been addressed when weinspected.

• Patient Group Directives (PGD’s) were in place on theunit. PGD’s ensure patients receive safe and appropriatecare and timely access to medicines, in line withlegislation.

• To take out (TTO) medication was arranged on transfer,or faxed from the consultant led unit.

• The women we spoke with told us that they had notreceived any medication whilst on the unit.

• We saw controlled drugs were checked during thehandover process, two midwives ensured the count wascorrect. Records showed this occurred twice a day.

• A controlled drugs audit carried out October 2016scored 100% . One query was raised within the auditwhich related to two midwives being required but notalways being available to check controlled drugs. Thisissue was resolved with the community midwifesattending the unit.

Records

• Patient paper records were stored securely in an officetrolley.

• Women were issued with a copy of their care plan,which they retained throughout their pregnancy.

• We reviewed two patient records and found them tohold relevant clinical information including riskassessments, which was legible, signed and dated inaccordance with guidelines.

• The trust conducted a records audit in November 2016.Forty five records from maternity service were reviewedincluding five sets of patient records from Oswestry MLU.The results showed that records were appropriatelykept. Improvements were required with ensuring the




patient’s name and unit number were consistently usedand entries were in chronological order. There was alsoa recommendation to review storage arrangements forassessment and investigation records.

Safeguarding

• The staff we spoke with told us they followedsafeguarding maternity guidelines and had attendedsafeguarding training. The unit attendance atsafeguarding training was recorded as Level 2 100% foradults and children and Level 3 88% with further datesfor attendance in the diary.

• Support plans were put into place to support womenwith additional needs including referral to theSupporting Women with Additional Needs (SWAN) team.This team visited the unit to ensure their needs andrequirements were being met.

• Staff we spoke to were able to confidently describedsituations, which would prompt a safeguarding concernand lead to a referral being made. Staff told us theywould contact the lead midwife for safeguarding withinthe trust or if ‘out of hours’ the social worker would becontacted with a faxed referral completed following thetelephone call.

• A new-born standard operating practice (SOP) was inplace for review in May 2018. This stated that thenew-born infant should be cared for in a secureenvironment to which access is restricted and a reliablebaby security system enforced, to minimise both clinicaland non-clinical risk issues for the most vulnerable.

• Women were given the opportunity to raise anyconcerns, confidentially with the midwife during clinicappointments or by contacting them by telephone. Nosafeguard referrals had been made during this reportingperiod.

• The trust told us and we saw evidence that mandatorysafeguarding training included child sexual exploitation,female genital mutilation and domestic abuseawareness and encouraged staff to access furthertraining through the Local Safeguarding Children Board.

Mandatory training

• We saw the maternity-specific mandatory trainingguideline, which included the training needs analysis for2016-2019. This detailed what was required formidwives, women’s support assistants and medical staffand how often. There were 35 modules in total andincluded appropriate modules such as obstetric

emergency multi-disciplinary skills drills, a fetalmonitoring package, newborn life support skills, earlyrecognition of the severely ill woman, post-operativerecovery skills and neonatal stabilisation. Compliancerates for all modules were provided at service level onlyand not brokn down by unit. Electronic fetal monitoringwas recorded at 80% and care of the severly ill womenrecorded as 95.8%. Neonatal stabilisation training wasrecorded as 82%. During the inspection, we were told byleaders at Oswestry that the compliance rate at the unitwas 100%. The target was set at 80%.

• Care group governance meeting minutes for November2016 showed that 84% of midwives, 74% of Women’sServices Assistants (WSAs) and 86% of obstetric medicalstaff were up-to-date with obstetric emergency skills.

• The statutory, mandatory training programme included16 topics such as patient moving and handling, adultbasic life support, slips trips and falls and equality anddiversity. At Oswestry this was completed during a ‘threeday’ annual mandatory training programme. Trustmandatory training competition target was 100%.

Assessing and responding to patient risk

• At each antenatal appointment women’s individual riskswere reviewed and reassessed.

• The trust had a clear policy on antenatal clinical riskassessment, setting out a colour coded criteria forwomen who were suitable for low (green) risk care(delivered by community midwives and MLU births),those who were medium risk and required closermonitoring (amber) and those classed as high risk (red)and needed care under a consultant. Midwives wereable to described this policy and confirmed that riskswere discussed with women at each stage of theprocess.

• When a woman reached 36 weeks of pregnancy, a finaldecision on the place of delivery was made. Decisionswere made involving midwives at the MLU and thewoman. Only women categorised as low risk were ableto deliver their baby at the MLU or their own home.Those with additional risks would be advised to delivertheir baby at the consultant led unit.

• A local survey of all women who gave birth at the trustduring September 2016, asked what women wereinformed about when choosing where to have theirbaby. The survey showed that 91.7% of women wereinformed that MLUs were staffed solely by midwives,




97.3% were aware that if a problem arose during labourthey may be transferred to the Consultant Unit and82.9%, were aware of how long it would probably taketo transfer from the MLU to the Consultant Unit.

• Early warning scores were recorded daily to monitor anypotential deterioration in a woman and new-born’scondition. The Modified Early Obstetric Warning Score(MEOWS) and National Early warning Score (NEWS) wasrecorded to detect the need for early intervention ortransfer of a woman or new born.

• The new-born’s NnEWS score was recorded at deliveryand subsequently monitored for several hours followingthe birth. Speaking with the midwife it was clear thatthey had the knowledge, skills and experience toappropriately escalate any concerns to the head ofmidwifery or on call doctor. We were told that with nohesitation when any new-born infant triggeredincreased assessment scores they would dial 999 toensure early transfer to the consultant led ward. We sawthese early warning score records were dated andsigned.

• We saw the trust’s perinatal sepsis guideline ‘Sepsisrelated to the antenatal, intrapartum and postnatalperiod’ due for review in September 2016. This includedthe nationally recognised ‘Sepsis 6’ care bundle and thematernity sepsis screening tool, in line with Sepsis TrustUK guidance.

• There was a policy and procedure in place for transfer ofdeteriorating patients. Midwifes followed the trust policyfor the transfer of women in labour to the main siteincluding the management of women or babies whoshowed signs of deterioration and required additionalcare. Women were transferred by ambulance from theMLU to the consultant led unit at Princess Royal Hospitalwith a telephone call made to inform the receiving unit.Staff told us that the process worked well and that theywere well supported by the consultant unit in thesesituations.

• The trust told us it does not currently audit the transferof women from the consultant unit to the MLU as this ispart of the planned process, however, they are planningan audit of handover of care between the CLU and theMLU during 2017/2018 as part of their audit programme.

• Between 01 November 2015 and 31 October 2016 therewere 39 transfers out of the MLU to the consultant ledunit at Princess Royal Hospital. The main reason fortransfer were recorded as delays in labour and fetalconcerns.

• We were told that the medical staff from Princess RoyalHospital were supportive and available at all times overthe telephone for advice and guidance. Scans and fetalmeasurements could be faxed to the consultant led unitfor review and second opinions.

• A service-wide review of transfers by ambulance to theCLU between April and September 2015 included datafrom five women transferred from Oswestry. The reviewconcluded that women were not being unnecessarilytransferred and outcomes for those who weretransferred were good.

• A birthing pool evacuation policy was in place, includingmanual handling guidance for care of the women. Eachwoman was risk assessed to use the pool prior to beingincluded in the birthing plan. The staff practiced ‘skillsand drills’ for the emergency removal of the womenfrom the pool should their blood pressure drop or thedelivery process change. The WSA explained how thepool was filled higher to remove the women with thesupport of a handling net and how the fast drain systememptied the water.

• The trust had a policy in place for the transfer ofpostnatal women from the consultant led unit to theMLU. The policy states that after an initial assessmentfollowing birth, women can be transferred if she and herbaby meet the criteria. The criteria excludes womenwho were less than 24-hours post caesarean sectionand/or were not mobile and babies who had not fed inthe first 12 hours, if they had neonatal jaundice thatrequires medical treatment, babies with a fetalabnormality, requiring nasogastric tube feeds or with atemperature of less than 36°C. There were 146 womentransferred for post-natal care between 1 November2015 and 31 October 2016.

Midwifery staffing

• The planned staffing levels were a minimum of onemidwife on the unit at all times. On Mondays andThursdays an extra midwife was rostered on to the unitto undertake clinics duties. An Ultrasonography midwifeheld a weekly scanning clinic.

• Staffing levels were displayed on the unit and we sawthat the MLU was continually staffed with one midwifeand one WSA. There were 10 staff employed on the unit.

• One community midwife was on duty covering theMarket Drayton and Whitchurch areas, working 7 and ahalf hours; they would attend the unit as necessary toprovide support during the day. An on call midwife




supported the night staff. When a home birth wasplanned, there would be two midwives on call for theduration required. Out of hours, there was a rota withone midwife on call during the night who may be calledto assist with the second stage of labour. An acuity toolwas used to record staffing levels and the manager sentreports monthly for this to be reviewed.

• Midwives from Oswestry told us they were not called into help out at the consultant led unit in Telford.

• Staff told us they did feel pressured at time, and workinghours may be longer than scheduled, but as a teamworked well together. The on call process did presentproblems when the midwife was rostered to work thenext day and had been on visits during the night. Theteam were flexible in supporting each other withswapping on calls to ensure sufficient rest was gained.This process was led by goodwill and not a formalarrangement.

• The unit did not use agency midwives, where there werestaffing shortages, cover was arranged internallythrough extra shifts for permanent staff or bank staff.

• There were no staff vacancies and there was no staff onlong-term sick leave. The manager told us that therewas a waiting list of midwifes who had requested towork on the unit.

• Staff told us that women received one-to-one care inlabour and there were always two midwives present atdelivery. An on call system was in place for the timearound the due date in order to facilitate this. Staffworked 12-hour shifts to cover these requirements. Inaddition to this, one midwife was on call during thenight in preparation of being called to assist with thesecond stage of labour when necessary.

• Formal handovers took place at the beginning and endof each 12-hour shift. Each woman was discussed andher care was reviewed.

• Post-natal checks were carried out in the community,however the community midwife arranged with thosewomen who were able, to attend the unit; this avoidedthem waiting in all day and assisted with the communityworkload.

• Student nurses and midwives were allocated to the unitas part of their training. We spoke with a studentmidwife from Staffordshire University who told us theyhad felt welcomed and on completion of their inductionthey were included in the MLU activity.

Medical staffing

• There were no medical staff working at the unit. Ifmidwives had concerns about a woman or baby theywould seek guidance from the labour ward at PrincessRoyal Hospital.

• We were told by staff that the medical support duringthe day, at weekends and during the night was veryresponsive. Transfers for review were arranged asnecessary without question.

• We were told that telephone conversations with medicalstaff were documented to evidence review of thewoman when their condition changed.

Major incident awareness and training

• Fire safety awareness training was included as part ofthe staff mandatory training course.

• Situated on the Robert Jones & Agnes Hunt Hospital sitethe unit had not heard about any incidents or securityissues from the site managers.

• The trust had a major incident and business continuityplan should the need arise. The MLU could be used ifissues within the midwifery beds occurred.

• Staff told us that they adhered to the lone worker policywhich was in place and accessible on the trust intranet.When working in the community, midwives would taketheir own mobile telephone as well as the unit phone;with a list of the addresses where they were goingavailable on the unit. This meant that if staff at the unitwere concerned about them or if they did not returnwhen expected they would try to contact them. Onoccasions when difficult situations had arisen, thepolice had escorted the midwives in the community.

Are maternity and gynaecology serviceseffective?

Good –––

We rated effective as good because:

• Care and treatment was delivered in line the currentevidence based guidelines. Staff adhered to the trustIntrapartum Care on a MLU or Homebirth policy (June2016), all trust wide policies and procedures wereavailable to staff on the intranet.

• Effective systems of communication were establishedbetween the consultant led unit and the MLU, ensuringthat effective care and treatment could be delivered.




• Pain relief was discussed with women and administeredin line with their birth plan where possible

• There was an effective approach to supporting staff;continual professional development and learningopportunities were promoted

• Verbal consent was gained between the mother andmidwife during examinations and the recording ofobservations

Evidence-based care and treatment

• In line with National Institute for Health and CareExcellence (NICE) Intrapartum Care Guidelines (2014),staff adhered to the trust Intrapartum Care on a MLU orHomebirth policy (June 2016). This ensured mediumand low risk women, who chose to give birth at home orin a MLU, received safe, evidenced-based care. Theservice audited compliance with NICE guidelines on anannual basis.

• In line with NICE Quality Standard 22, antenatal careincluded screening tests for complications of pregnancyand the antenatal care of all pregnant women up to42weeks of pregnancy. This included primary,community and hospital-based care.

• A risk and needs assessment including obstetric medicaland social history was carried out, to ensure thatwoman had a flexible plan of care adapted to her ownparticular requirements for antenatal care in line withRoyal College of Obstetricians and Gynaecologists 2008guidelines (RCOG 2008).

• Effective systems of communication were established,between all team members and each discipline, as wellas with the women and their families and was in linewith RCOG 2008.

• Trust wide policies and procedures were available onthe intranet with key documents printed off as required.

• Maternity guideline meetings were held monthly. Twomidwives reviewed new guidelines to ensure theyreflected current practice; these were also discussed atmaternity feedback meetings.

• We saw minutes of the monthly guideline meetingswhere two ‘guideline midwives’ discussed new guidancein line with NICE.

• The results showed that for most of the areas the trustachieved above 90%; mothers stated they had receivedadequate support. The percentage of babies provided

with supplements to breastmilk should be below 20%however the trust had supplemented 24%.The score formother’s being shown how to hand express breast milkonly just passed with a score of 81%.

Pain relief

• Women we spoke with confirmed that their pain hadbeen well managed and in line with their request.

• A variety of pain relief sources was available to womenincluding tablets, injections and gases such as Entonox.A birth pool was available for women to choose wateremersion for pain relief in labour.

• Staff told us that pain relief was discussed with womenand administered in line with their birth plan wherepossible.

Nutrition and hydration

• The women we spoke with were satisfied that they hadreceived adequate meals and hydration. There was achoice of hot and cold drinks and meals were orderedfrom a menu system. Women could walk to therestaurant in the main hospital if the wished.

• The MLU was accredited with the UNICEF Baby FriendlyInitiative (BFI). We saw that the unit promotedbreastfeeding and the important health benefits of thisfor mother and baby. We saw information postersavailable and staff told us they discussed this withmothers at all stages of pregnancy and post-delivery ofthe baby. A lactation consultant was available tosupport women and offer advice to the midwives whenbreast feeding was not possible.

Patient outcomes

• In 2015, the Secretary of State for Health announced anational ambition to halve the rates of stillbirths,neonatal and maternal deaths and intrapartum braininjuries in babies by 2030, with a 20% reduction by 2020.The trust had recently ‘signed up to safety’ to contributeto the NHS England ambition to improve maternityoutcomes.

• The midwife to birth ratio for the trust from April toNovember 2016 was 1:30 and was in line with therecommended target of ‘Birth-rate Plus’. The dataprovided was trust-wide and not broken down by unit.We were unable to determine the midwife to birth ratiofor the MLUs.




• The trust wide percentage of women having their babiesat home was 1.3% as of November 2016 and this wasthe percentage for 2015/16 overall. This was just belowthe national England average for home births of around2%.

• Maternal smoking status at the time of delivery datashowed that the trust had a rate of 16% from April toNovember 2016 and 15% for 2015/16, which was betterthan the locally agreed target of 20%.

• A trust wide audit was conducted involving 43 motherswho were interviewed about the breastfeeding supportthey had received while under their care. Questionsincluded the support provided by staff at birth, learningabout breastfeeding, food and fluids provided otherthan breastmilk, relationship building between motherand baby and antenatal care. The results showed thatfor most of the areas the trust achieved above 90%;mothers stated they had received adequate support.The percentage of babies provided with supplements tobreastmilk should be below 20% however the trust hadsupplemented 24%.The score for mother’s being shownhow to hand express breast milk only just passed with ascore of 81%.

• During 2016, the service introduced a maternitydashboard that identified performance and key patientoutcomes benchmarked against the RCOG maternitydashboard. Oswestry MLU demonstrated 100% normaldelivery which was better than the local target of 85%,less than 4% manual removal of placenta, which wasabove the expected range of 0-2% and less than 4%third or fourth degree tears reported, which was withinthe expected range of 0-5%

• Zero stillbirths were reported for this unit.• There was two maternity readmission between

September 2015 and August 2016. One admission inJanuary 2016 and one in February 2016.

Competent staff

• The service has a policy and procedure in place that setout the process for rotation of midwives in order toassist in supporting staff to gain experience in key areasof Midwifery and to refresh skills. A list of those rotatingis produced every April and October. The serviceundertook a survey of midwives in May 2016, of the 213respondents across all areas, 70% of midwives said theythought their clinical practice was enhanced.

• Post inspection, the trust provided us with evidence ofnewly developed midwifery competencies for all

employed midwives. This was to commence in February2017 and we saw the agenda for this programme. Thisincluded the importance of midwifery competencies,accountability, implementation and monitoring of thesecompetencies.

• To support women attending the ward, one midwife hadsecured a place on a hypnobirthing course. Womencould opt for hypnobirthing at the unit. Hypnobirth is aterm used to describe the use of hypnotherapytechniques to relax the mother-to-be during labour andbirth. In line with the birthing process, there are twophases to the hypnobirthing process, preparation anddelivery.

• Trust guidelines and policy updates were discussedduring staff meetings including future models of care toensure staff are kept up to date and any training needsare identified.

• A preceptorship package was in place for newlyqualified midwives, which included a specific structuredrotational programme. This process ensured that themidwifery workforce maintained their skills andprovided flexibility with service provision.

• Current appraisal rate was 79% with 15 of the 19 staffhaving received their appraisal. The remainder of thestaff were planned to be completed within the annualappraisal programme.

• Staff told us they attended continual professionaldevelopment and learning opportunities which werefully supported by the ward manager. Arrangements tochange how current clinical supervision was deliveredwere in the discussion stage along with supervisor ofmidwives changing role.

• There was a structured induction programme for newmembers of staff to work through. All new staff wererequired completed an induction booklet, which wassigned off by the ward manager.

Multidisciplinary working

• The staff described robust multidisciplinary workingthat was effective. Good communication and links withlocal GP’s ensured the women had the support theyrequired when discharged.

• Staff described a good working relationship with all staffin the trust. When staff at the MLU had any concernsduring antenatal checks they would contact the earlypregnancy unit or labour ward at Princess Royal




Hospital to review the information with a senior midwifeor medical staff. They described a positive workingrelationship and could refer women to be seen andarrange urgent scans when necessary.

• The maternity service promoted multidisciplinary teamworking, including antenatal services. Communitymidwives, health visitors and social services staffpromoted joint working.

• Daily communication with the community maternityteam ensured good working relationships weremaintained between all the staff.

Seven-day services

• The MLU was open 24 hours per day, seven days perweek.

• An on call system was in place to ensure that for womenreaching the second stage of labour during the night asecond midwife would attend for the delivery of thebaby. Out of hours, there was a rota with one midwife oncall during the night who may be called to assist withthe second stage of labour.

Access to information

• The trust record management system ensured that thestaff had the appropriate access to relevant notes toassist them with care of the women and their babies.

• Staff had access to up-to-date policies, procedures andtreatment guidelines via the trust’s intranet. This systemwas accessible and staff were able to show us where tofind policies and protocols as well as trust wide updates.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• Staff told us they provided as much information aspossible before gaining consent. Verbal consent wasgained between the woman and midwife duringexaminations and the recording of observations. Thiswas confirmed by the women we spoke to and therecords we looked at. Staff showed good awareness ofthe procedure to follow regarding the Mental CapacityAct and the importance of informed consent.

• One deprivation of liberty safeguard was reported bymidwives in the unit between 01 November 2015 and 31October 2016.

Are maternity and gynaecology servicescaring?

Good –––

We rated caring as good because:

• Results of the NHS friends and family survey showedthat the proportion of women who would recommendthe service was better than the England average.

• Women told us that they felt very well cared for and thestaff were caring, thoughtful and compassionate

• We were told that women were monitored for theirwellbeing at all stages of the pregnancy and followingthe birth. Assessments for anxiety and depression wererecorded throughout their care.

• When necessary counselling services were arrangedthrough discussion with the women, the GP and themidwife to provide emotional support where needed.

Compassionate care

• The trust participated in the NHS Friends and Familysurvey. Between August 2015 and August 2016, theresults for the antenatal care survey showed that theproportion of women who would recommend theservice was better or similar to the England average forthe same period. This was also the case for the birth,postnatal ward and postnatal community survey results.

• For August 2016, the trust’s performance for antenatalwas 96%, for birth was 100%, for postnatal ward was99% and for postnatal community was 100%.

• We observed staff interacting with women in their carein a caring and compassionate manner.

• Women we met on the ward told us that they felt verywell cared for and the staff were caring, thoughtful andcompassionate.

• The staff on the ward had received many thank youcards and letters of appreciation. .

Understanding and involvement of patients and thoseclose to them

• Women on the ward told us they had been fully involvedwith their care plan and felt very well supported by allthe unit staff.

• We were told that the partners were also encouraged tobe involved during the delivery and following the birth.

• We heard from women that additional support wasoffered when required and they were encouraged to ringin to the unit with any queries.




Emotional support

• Staff told us were told that women were monitored fortheir wellbeing at all stages of the pregnancy andfollowing the birth.

• We were told that assessments for anxiety anddepression were recorded throughout their care. At 16weeks post-delivery, the midwives discussed theirgeneral feelings regarding mental health and assessedthe need for further support.

• The supervisor of midwives was debriefed about anywomen in the unit or the community, when their mentalhealth had raised concern.

• Bereavement counselling was available for staff to referwomen to if they required following the loss of a baby.

• When necessary counselling services were arrangedthrough discussion with the women, the GP and themidwife.

• Occupational health support was available for midwivesand unit staff requiring emotional support.

Are maternity and gynaecology servicesresponsive?

Good –––

We rated responsive as good because:

• Systems were in place to ensure the service wasmeeting the individual needs of women using theservice. For example, a five week parent craft course washeld at the GP Clinic, with a monthly, condensed course,held at the MLU on Saturdays; enabling both parents toattend where possible

• In the CQC Maternity survey 2015 the trust performedbetter than others for patients feeling their length of stayin hospital was appropriate

• Staff were aware of the information women wouldrequire if they wanted to make a complaint and wereclear of the procedure.

Service planning and delivery to meet the needs oflocal people

• The MLU promoted a ‘home from home’ experiencewhere partners were made welcome and could accessfacilities as well as the women. Partners had openvisiting to the unit.

• There were 62 births at Oswestry MLU. Midwives basedat the unit also provided community care to the localarea; there were 275 births within the communitymidwife area during the reporting period. There were163 admissions to the MLU, which included women whohad chosen to give birth at the unit but were transferredto the consultant unit and those who chose to receivepostnatal care at the unit.

• Anti-natal clinic appointments, held at the unit, werescheduled to meet the needs of the families; drop insessions were promoted to reassure women if they feltreduced movements or wished to hear the fetalheartbeat.

• Tours of the unit were arranged during the anti-natalappointments for the women and their birth partner.

• A five week parent craft course was held at a GP Clinic,with a monthly, condensed course, held at the MLU onSaturdays to allow both parents to attend wherepossible. Individual parent craft sessions were arrangedwhen women required further support.

Access and flow

• Women could access the maternity services forantenatal care via their GP or by contacting thecommunity midwives directly.

• Women were able to receive care at the unit if they wereclassified as being low risk and/or if they opted forsupport following the birth of their baby. Staff told usthat it was rare that women were unable to have a placeat the MLU.

• In the CQC Maternity survey, 2015 the trust performedbetter than others for patients feeling their length of stayin hospital was appropriate.

• Admissions in to the unit were planned following theinitial risk assessment at the first booking appointment.Re-admissions were booked through the consultant ledunit or the GP.

• Community midwives also re-admitted women whenthey identified that increased support would bebeneficial to the women and new-born.

• Women we spoke with were aware of when they werepotentially due to go home. Discharge information wasissued to women with advice and guidance notes.

• Post-natal follow up care was arranged as part of thedischarge process with community midwives.

Meeting people’s individual needs




• Women who were cared for on the MLU told us that theywere given a choice following a thorough andcontinuing risk assessment process. They fullyunderstood they were required to follow the advice ofthe midwives in line with the trust guidelines.

• Information leaflets were available for women to takefrom the unit offering pregnancy advice and guidance.

• Women requiring extra support were visited by theSWAN midwife. They were able to advice and guidewomen who required physical, financial or mentalhealth support.

• Women with learning disabilities were supported on theunit; their carer was encouraged to remain with them atall times. Extra time was allowed for appointments andhome visits to ensure they fully understood the careplanned and the events which would take place.

• The birthing pool was available for all women followinga risk assessment. Midwives told us they explained towomen that if they were assessed as suitable to use itand it was available then they could be cared for in thepool environment.

• Chaperone policy was in place, which ensured allwomen were appropriately supported andaccompanied during intimate examinations.

• Telephone translation services were available whenrequired. Conference calls and face-to-faceappointments were organised throughout the antenatalstage.

Learning from complaints and concerns

• We saw that staff had access to the trust policy forcomplaints on the intranet and knew about the PatientAdvice and Liaison Service (PALS), which supportspatients with raising concerns. There were posters withthis information displayed on the unit.

• Staff told us that if any women raised a concern or issuewhilst at the unit they would apologise, try to findresolution and escalate to the manager of the unit.

• No complaints had been received at the unit during theprevious 12 months. When issues or concerns wereraised the team discussed these at ward meeting toavoid them re-occurring.

• Information regarding how to complain, includingposters, were visible on the unit.

Are maternity and gynaecology serviceswell-led?

Good –––

We rated well-led as good because:

• A full review of the maternity service was ongoing,looking at different ways to improve the service withmodels of care being scoped by the trust.

• Midwives were clear about their role and levels ofaccountability.

• Staff told us they felt informed by the managers andreceived appropriate feedback from meetings andthrough the intranet.

• The service was centred on the women receiving goodlevel of care and support.

Leadership of service

• The care group management team consisted of a caregroup director, a head of midwifery (HoM) and a caregroup medical director. The HoM and the care groupdirector came into post in September 2016. There was alead midwife for community services who wasresponsible for all MLUs within the trust. There was amanager responsible for the day to day running of theunit, who reported to the lead midwife.. Although thesemanagement arrangements were in place to ensurejoined-up working, we saw that the unit mostlyoperated independently of the consultant led unit.

• The unit manager was responsible for the running of theunit including staffing, community midwife support andsafety of the women and babies. Staff told us thatmanagers of all levels were visible and very much part ofthe team.

• Local leadership was described as supportive andapproachable. Midwives told us that they wereconfident that they were listened to but did feel nervousabout the future changes to the unit, which wereimminent in 2017.

• All staff told us they felt informed by their seniormanagers who visited the unit and were kept up to datethrough feedback from meetings and through theintranet.

• We were told that the chief executive visited the unitduring the previous year, the new head of midwifery hadyet to visit and no board members had visited.

Vision and strategy for this service




• The trust values, now included in the appraisal processwere, proud to care, make it happen, we value respect,together we achieve. These were displayed on the unit;staff were aware of these and displayed them in theirwork and attitudes towards their role working for thetrust.

• The philosophy of care was to aim to deliver high qualitymaternity care throughout pregnancy, birth and thepost-natal period, ensuring that the birth of a child is asafe, life enhancing experience for the woman, herpartner and family.

• Staff were aware of the full review of the maternityservice was ongoing, looking at different ways toimprove the service with models of care being scopedby the trust. The midwives understandably felt anxiousabout the possible changes to their workingarrangements.

• The midwives were fully aware and engaged in the truststrategies and the possibility of future reorganisation ofthe service in 2017.

Governance, risk management and qualitymeasurement

• There was a clear governance committee structure withdirect reporting from the MLU to the care groupleadership team.

• The care group governance committee received regularreports on quality performance, patient experience,serious incidents, complaints, audit and risk. Thesereports included information from the MLUs. We sawevidence of this in meeting records.

• The MLU did not have its own local risk register. All riskswere recorded on the care group risk register, which wasreviewed and updated monthly. We saw that the riskregister identified and reflected the risks at MLUs suchas IT system failures. Risks and responsible owners wereappropriately assessed, reviewed and escalated.

• During 2016, the service introduced a maternitydashboard that identified key performance indicatorsand patient’s outcomes for each MLU, benchmarkedagainst the Royal College of Obstetricians andGynaecologists (RCOG) maternity dashboard.

• During this inspection, we found that the trust weretaking previous failures seriously and saw evidence ofsome changes taking place across all the MLUs. We sawthat the service recognised they were in a transitionperiod and that continued improvements were

required. An external review of governance processes,was in progress at the time of our inspection. Seniormanagers told us this was because they recognisedthere was potential to make improvements.

• Midwives we spoke with were clear about their role andlevels of accountability.

• Quality issues were escalated to head of midwiferythrough discussion and formally through the electronicreporting system.

• Quality and safety issues were measured on thematernity dashboard. In August 2016 quality and safetyreport for Oswestry 100% of women who were admittedhad been assessed for VTE. Hand hygiene on the unitscored 100% and excellent parentcraft sessions werehighlighted.

• Minutes of the monthly ward meetings demonstratedthat staff were informed and familiar with the trust’squality and safety issues and those relevant to the unit.

Culture within the service

• There was a strong emphasis on promoting safety andwell-being of staff and they told us they did feel theywere a strong team who supported each other.Occupational health facility was available shouldenhanced support be required.

• The staff we spoke with told us they felt respected andvalued.

• We heard about a service, which was centred on thewomen receiving a good level of safe care and thenecessary support.

• Staff was encouraged to forward ‘good news’ stories tothe trust, celebrating successful outcomes and ‘happy’events.

Public engagement

• FFT feedback was recorded to listen to the public voice.Feedback of this method was minimal and the staff werelooking at ways to encourage a higher percentage ofreturns. However, the women and their families hadsent in positive feedback directly to the unit in the formof cards, letters and pictures.

• Women who lived locally told us that they hoped todeliver at the MLU as it had a good reputation of havingcaring staff and a good safety record.

• There was a quarterly maternity engagement group,which was a multi-agency meeting with a representativefrom the CCG, Healthwatch Shropshire, a supervisor of




midwives, the HoM, the patient experience team andservice users. We saw meeting minutes for September2016 where patient experiences were shared andactions developed for areas of improvement.

Staff engagement

• Monthly ward meetings with the staffs’ own agendaensured that the staff felt engaged and their views wereheard. The staff felt engaged and part of the trustespecially with the rotation of midwives into thehospital. Staff felt able to raise issues and concerns; theyfelt valued by the managers.

• Staff told us their ideas were listened to and they feltvery engaged with changes to the service and up to datewith the progress of their suggestions. Staff at the unithad participated in the trust wide midwifery survey,which had been used to gain views on how to moveforward with the service.

• Noticeboards displayed lots of information about thematernity service and general information about thetrusts upcoming events and changes to policies,procedures and protocols.

Innovation, improvement and sustainability

• On occasions, local school children had been acceptedfor work experience following discussion with the headof midwifery.

• One midwife, in her own time, had recently completed ahypnobirthing training course to be able to supportwomen who chose this option during labour.

• The on going review of maternity services wasconsidering the sustainability of all the MLU’s across thetrusts.




Areas for improvement

Action the hospital SHOULD take to improve

• The trust should ensure the unit safety dashboard isavailable and shared with staff.

• The trust should ensure equipment is stored safelyand out of reach of children.

Outstandingpracticeandareasforimprovement

Outstanding practice and areas for improvement


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