The Royal Cornwall Hospitals NHS Trust is the principal provider of acute care services in the county of Cornwall. The Trust serves a population of around 532,273 people, a figure which can be doubled by holiday makers during the busiest times of the year.
The trust maternity services provide antenatal, intrapartum and postnatal care in the Royal Cornwall Hospital and within local community settings divided into three geographically based community midwife teams including Penrice Birthing Centre which is located in the grounds St Austell Community Hospital.
The maternity services are part of the women, children and sexual health division of the trust. A community midwife team leader manages Penrice Birthing Centre on a day to day basis and reports to the community midwifery matron at Royal Cornwall Hospital.
This is an announced focussed inspection of Royal Cornwall Hospitals NHS Trust to assess if improvements have been made following the previous unannounced focussed inspection carried out in January 2017. We inspected the centre as part of this inspection on 6 July 2017.
We rated Penrice Birthing Centre as requires improvement overall.
Our key findings were as follows:
There were areas of poor practice where the trust needs to make improvements:
- Staff at the birth centre did not audit their activity to provide assurance of delivery of care in line with trust guidelines and its effectiveness.
- The transfer rate to hospital from the birth centre was higher than the national average and the service had not analysed this fully.
- A number of risks such as ambulance delays and whether all community midwives had the skills to deal with some emergencies while awaiting an ambulance were not on the risk register at the time of the inspection, although the trust added these in August 2017 after we raised concerns. There was no local risk register for the Penrice birth centre or the regional community midwifery service.
- There was no community midwifery dashboard to give an oversight of community performance and no documentation audits to assure managers that all midwives were following guidelines.
- There had not been a full risk assessment of lone working arrangements involving community midwives themselves, for the new model of care when the first on call midwife attends the birth centre.
- There was no audit plan for community midwifery to provide assurance of effective delivery of care in line with trust guidelines.
- Conflicting advice in guidelines about incident reporting was confusing: for example the trigger list for incident reporting in the Maternity Risk Management strategy contained different advice to the Home birth guideline.
- Not all midwives were up to date with their mandatory training and compliance was set at a lower level than 95% target for training completion set by the trust.
- There was no documented vision and strategy for the birth centre and community midwifery.
- Midwives did not have clear written guidance about MEOWS and obstetric emergencies in the community. There was no written guidance on baby weight loss.
- There was no benchmarking of processes against comparable trusts in rural areas.
- Community midwives felt remote from strategic decision-making.
Importantly, the trust must:
- Ensure there is a review and full risk assessment of lone working arrangements under the new model of care when the first on call midwife attends the birth centre.
- Identify, analyse and manage all risks of harm to women in maternity services, ensuring local risk registers are maintained in all discrete units and feed into the divisional and corporate risk register.
- Ensure all midwives update their training to a level where they all have the skills needed for their roles, and set targets for completion of training in line with trust targets of 95%.
- Ensure better quality data about processes and outcomes within the maternity services is available for analysis and to support improvement.
- Ensure that systems are in place so that governance arrangements, risk management, and quality measures are effective. Ensure audits are aligned to incidents and identified risks.
- Ensure the maternity dashboard includes sufficient information to provide a comprehensive overview of maternity performance. Proactively benchmark processes and outcomes in the maternity service against comparable trusts in rural areas.
In addition the trust should:
- Consider developing a community specific dashboard display to give a comprehensive overview of community maternity performance. .
- Clarify whether midwives should record all intrapartum transfers from the community as incidents.
- Review the back-fill arrangements when midwives working on call have to work at night to ensure they are fit to work their shift next day.
- Consider how the vision and strategy for the birth centre and community midwifery are documented and communicated.
- Develop clear written guidance for midwives about maternal observations, managing community obstetric and neonatal emergencies, baby weight loss and feeding concerns.
- Develop policies and guidelines with more involvement of a range of relevant staff, particularly those who will need to implement the policy or are affected by it.
However, there were areas of good practice including:
- The birth centre offered women a compromise between home and hospital in a clean, relaxed, non-clinical environment.
- The birth centre offered facilities that were not currently available in the hospital: spacious accommodation with labour aids such as birth balls, padded mats and birth stools and a pool for pain relief or water birth.
- Community midwives offered care before, during and after birth which gave reasonable continuity of care to women within reasonable distance of their homes
- Women wanting to give birth at the centre were screened appropriately to ensure they were low risk.
- Care was delivered with kindness and compassion. Patients and their partners were involved and emotional support was good.
- Incidents were reported and there was evidence of learning as a result.
- The trust achieved a much higher community birth rate than the national average: 11.4% compared to 2% nationally.
We also saw the following outstanding practice:
- The trust had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.
Professor Edward Baker
Chief Inspector of Hospitals