The Care Quality Commission
  • Hospital
  • NHS hospital

Liverpool Women's Hospital

Overall: Good read more about inspection ratings

Crown Street, Liverpool, Merseyside, L8 7SS (0151) 708 9988

Provided and run by:
Liverpool Women's NHS Foundation Trust

All Inspections

15 January 2024

During an inspection looking at part of the service

Liverpool Women’s NHS Foundation Trust is a specialist trust that specialises in the health of women, babies, and their families. It is one of only two specialist trusts in the UK and the largest women’s hospital in Europe. As a tertiary centre the hospital provides care for a significant proportion of patients with high levels of complexity and clinical risk, as well as serving a local population with significant deprivation. The hospital teams deliver around 8,000 babies each year. The maternity team cares for women and their babies from conception to birth supported by the neonatal team who provide around the clock care for premature and new-born babies needing specialist care.

The trust also delivers neonatal, end of life care, outpatients, gynaecology, fertility and termination of pregnancy services but these were not included in this inspection.

In January and February 2023, we carried out a focused inspection of maternity services as part of the CQC national maternity inspection programme which looked only at the safe and well led questions. We also inspected the well-led key question for the trust overall. Following the inspection, we issued a Warning Notice to the trust in accordance with Section 29A of the Health and Social Care Act 2008.

We undertook this focused inspection to follow up the Warning Notice and did not cover all of the safe and well-led domain, therefore the ratings remain unchanged. We found:

  • Staff routinely carried out checks of emergency equipment.
  • Staff completed and updated risk assessments for each woman and took action to remove or minimise risks.
  • The service had enough staff to keep women safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix.
  • There were leadership structures in place to maintain oversight of the service.

However:

  • We found out of date items on emergency trollies and the system used to carry out checks of emergency equipment was not always fit for purpose.
  • Staff did not always use the Modified Early Obstetric Warning Score (MEOWS) tool effectively to identify women at risk of deterioration.
  • Performance data was not always accurate.

Following this inspection, we determined the Section 29A Warning Notice that we issued to the trust in February 2023 had been complied with.

24 to 25 January

During a routine inspection

We inspected gynaecology services at Liverpool Women's Hospital as part of the comprehensive inspection of Liverpool Women's NHS Foundation Trust. We also carried out a short notice announced focused inspection of the maternity service, looking only at the safe and well-led key questions, as part of our national maternity services inspection programme.

Gynaecology

The Liverpool Women's NHS Foundation Trust gynaecology division, is a tertiary referral centre for gynaecology, performing approximately 10,000 procedures per year. The division primarily runs the services from the main hospital site at Crown Street, but also has sites at Aintree. The division has a number of services within it, fertility medicine, inpatient gynaecology and day case, colposcopy and hysteroscopy, ambulatory care, a gynaecology emergency department, a termination of pregnancy unit, a two bedded high dependency unit and gynaecology oncology.

The Bedford Unit provides termination of pregnancy services including early medical abortion (up to 16 weeks plus 6 days gestation) and surgical abortion (up to 12 weeks plus 6 days gestation).

We carried out an unannounced comprehensive inspection of gynaecology and termination of pregnancy using a risk-based methodology and a combined core service framework. Two inspectors and a specialist advisor were on site for two days, with offsite support from an inspection manager, head of inspection and data analysts.

We had the opportunity to speak with 4 patients using the service and looked at patient feedback shared with the commission prior to inspection. We also spoke with 41 different members of staff working across the service.

We reviewed service 15 combined electronic and paper patients’ records.

See main report for overall summary and findings.

Our rating of this service improved. We rated it as good because:

  • The service had enough nursing staff to care for patients and keep them safe. Nursing staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They mostly managed medicines well. The service learned lessons from safety incidents. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
  • Staff treated patients with compassion and kindness, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually. The Bedford Unit had been awarded an internal Gold rating on 14 October 2022 for ‘Be Brilliant Accreditation System’(BBAS) for KPI compliance.

However

  • Completion rates in some mandatory training for medical staff were low, and key learning regarding the Oliver McGowan Mandatory Training on Learning Disability and Autism was still being planned. Although electronic records showed equipment had been checked, some equipment did not display test servicing dates. Some medicines delivered by post for termination of pregnancy had been incorrectly delivered, however this related to one incident relating an external delivery company. Medical staff were not always available in a timely way to complete patient reviews in some parts of the service. The service used systems for managing patient safety incidents, although historically there had been some delays in reporting serious incidents, but this had improved.
  • We requested but did not receive data for completed appraisals for medical staff.
  • Women’s privacy and dignity was not always maintained when attending for day case admissions.
  • Key services were not always available seven days a week. People could not always access the service when they needed it and often had to wait too long for treatment, particularly for cancer pathways and scan services.

Maternity

We inspected the maternity service at Liverpool Women’s Hospital as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out a short notice announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

The inspection was carried out using a post-inspection data submission and an on-site inspection where we observed the environment, observed care, conducted interviews with patients and staff, reviewed policies, care records, medicines charts and documentation.

Following the site visit, we conducted interviews with senior leaders and reviewed feedback from women and families about the trust. We ran a poster campaign during our inspection to encourage pregnant women and mothers who had used the service to give us feedback regarding care. We analysed the results to identify themes and trends.

Liverpool Women’s Hospital is the main site for maternity services for the trust. It comprises of a delivery suite with maternity theatres, induction of labour beds and some enhanced recovery rooms. There is a 52 bed post and antenatal ward called Mat Base, which also contains transitional care beds. The service has a maternity assessment unit (triage) and early pregnancy assessment unit (which is part of the gynaecology emergency department). The service also has fetal medicine and maternal medicine units which provide services to women and birthing people from across the Merseyside, Cheshire and Northwest region. Ante and postnatal clinics are also provided at this location and there is an alongside midwifery led birth unit.

The local maternity population come from higher levels of deprivation than the national average with 47% in the most deprived decile compared to 13% nationally. Fewer mothers were Asian or Asian British or Black or Black British compared to the national averages.

During our inspection we spoke with staff including midwives, student midwives and doctors, maternity support workers, midwifery matrons, junior doctors, middle grade obstetricians, consultant obstetricians, as well as administration and clerical staff and senior managers. We also spoke to 9 women, birthing people and families.

Following this inspection, under Section 29A of the Health and Social Care Act 2008, we issued a warning notice to the provider. We took this urgent action as we believed a person would or may be exposed to the risk of harm if we had not done so.

Our rating of this service went down. We rated it as requires improvement because:

  • Not all staff had training in key skills.
  • Some staff did not always adhere to infection prevention and control best practice. Cleaning records were up-to-date but they did not always demonstrate that all areas were cleaned regularly.
  • Staff did not consistently assess risks to woman and birthing people nor act on them. Frequent staff shortages increased risks to women and birthing people across the maternity service.
  • Women and birthing people could not always access the service when they needed it nor receive treatment within agreed timeframes and national targets.
  • The service did not always have enough maternity staff to keep women safe from avoidable harm and to provide the right care and treatment. Staffing levels did not always match the planned numbers.
  • Staff did not always keep good care records.
  • Staff did not always use systems and processes to safely prescribe, administer, record and store medicines.
  • The service did not always manage safety incidents well nor learn lessons from them.
  • Staff felt did not always feel respected, supported and valued. They were not always able to focus on the needs of women and birthing people receiving care.
  • Leaders did not operate effective governance systems. They did not always manage risk, issues and performance well. They did not consistently monitor the effectiveness of the service. Though staff were committed to improving services they did not always have the skills and resources to do so.
  • Managers did not always ensure staff were competent. Not all staff had received an annual appraisal.

However:

  • Staff worked well together for the benefit of women and birthing people and understood how to protect women and birthing people from abuse.
  • Local leaders had the skills and abilities to run the service and were visible and approachable in the service for women and birthing people and staff.
  • Staff understood the service’s vision and values, and how to apply them in their work. Staff were clear about their roles and accountabilities.
  • The service engaged well with women and birthing people and the community to plan and manage services.

How we carried out the inspection

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

28 July 2020

During an inspection looking at part of the service

Liverpool Women’s NHS Foundation Trust is a specialist trust that specialises in the health of women, babies and their families. As one of only two such specialist trusts in the UK and the largest women’s hospital in Europe the trust holds a unique position.

Liverpool Women’s Hospital is the main hospital and is a modern landmark building near Liverpool city centre. It is here that the team deliver around 8,000 babies and perform some 10,000 Gynaecological procedures each year.

The maternity team cares for women and their babies from conception to birth supported by the neonatal team who provide around the clock care for premature and new born babies needing specialist care. The trust’s fertility team helps families to improve the chance of conceiving babies. In gynaecology, the trust undertakes care of women with the many varied conditions associated with the female reproductive system and is a centre for gynaecology oncology. The genetics team supports families with the diagnosis and counselling of genetic conditions.

On average 20 babies and three premature babies are born and cared for daily, the trust is primarily known for maternity and neonatal services. However, the trust also carries out 30 gynaecology operations and the reproductive medicine unit completes six cycles of IVF treatment every day.

We did an unannounced focused inspection of Liverpool Women’s Hospital; the trust was given 48-hours’ notice of our inspection. This was because at our last inspection we found concerns relating to the safe and proper management of medicines in gynaecology, maternity and neonatal services. We visited maternity and neonatal services and gynaecology services including theatres. We spoke to staff in all three core services and senior managers.

We did not rate the hospital at this inspection as we only inspected one key line of enquiry to ensure the hospital now managed medicines safely. We found the following improvements:

  • The hospital now used systems and processes that ensured the safe prescribing, administering, recording and storage of medicines. This was in all core services inspected, maternity, gynaecology and neonatal services.

03 December to 05 December 2020

During a routine inspection

Our rating of services stayed the same. We rated it them as good because:

What this trust does

Maternity Services: The maternity service has a 22 bedded consultant led labour ward encompassing a maternity theatre complex, an induction of labour suite and a maternity assessment unit with an additional co - located midwifery led unit.

Gynaecology Services: The trust provides specialist services for urogynaecology, bladder and prolapse conditions and miscarriage. The trust is a specialist regional centre for cancer services, known as gynaecology oncology within the Merseyside and Cheshire Cancer Network. There is a 24-hour gynaecology Emergency Room and an Early Pregnancy Assessment Unit, giving rapid access to medical treatment and ultrasound scans for women who experience a gynaecology emergency especially in the early stages of pregnancy.

Neonatal Service: The Liverpool Women's NHS Foundation Trust provides tertiary neonatal services to the Cheshire and Mersey Neonatal Network and the wider Northwest Neonatal Operational Delivery Network (NWNODN) if needed. The trust also accepts babies from the Isle of Man and North Wales. The Neonatal Intensive Care Unit (NICU) has the capability to treat extreme preterm babies, babies who require ventilation, cooling, and laser eye surgery.

The Hewitt Fertility Centre: The centre gives couples the chance of a successful pregnancy. The Trust has substantially invested in the very latest technologies to get success rates of the centre to the point where they are comparable to anywhere else in the country. The centre is the largest reproductive medicine facility in the country, performing an average of over 3,000 treatment cycles a year

Merseyside and Cheshire Genetics Service: The trust provides a regional genetics service serving a population of around 2.8 million people across Merseyside, Cheshire and the Isle of Man.

Key questions and ratings

We inspect and regulate healthcare service providers in England.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led?

Where we have a legal duty to do so, we rate the quality of services against each key question as outstanding, good, requires improvement or inadequate.

Where necessary, we take action against service providers that break the regulations and help them to improve the quality of their services.

What we inspected and why

We plan our inspections based on everything we know about services, including whether they appear to be getting better or worse.

We inspected Gynaecology as the service required improvement in safe at the hospital at the last inspection in 2018. We inspected maternity and neonatal services provided by this trust at its main hospital as part of our ongoing inspection programme.

What we found

Overall trust

Our rating of the trust stayed the same. We rated it as good because:

Overall we rated safe, caring, responsive and effective as good at acute and community service level.

We rated well led for the trust as requires improvement.

This gave a combined quality rating of good.

Are services safe?

The safe domain in maternity services remained good. Staff recognised and reported incidents well. However, initiatives for shared learning to reduce recurrence still needed to be fully embedded into practice.

Safety systems, processes and standard operating procedures were reliable or appropriate to keep women and babies safe. Staff followed policies and national guidance.

Staff identified potential safeguarding risks, involved relevant professionals and had systems in place to manage it.

The service had enough staff with the right qualifications, skills, experience and training to keep patients safe from avoidable harm and abuse, and to provide them with the care and treatment they needed.

The safe domain in neonatal services remained good. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.

The neonatal service had enough medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix and gave locum staff a full induction.

The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service.

The safe domain in gynaecology service at Liverpool Women’s Hospital remained requires improvement.

Areas for improvement at the last inspection for the gynaecology service we inspected remained a concern including;

The service did not always have enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Mandatory training and safeguarding compliance rates were low at the time of inspection.

Risks to patients were not consistently well-managed, for example; managers were unaware of the concerns we raised relating to young people until they were raised at the inspection. We raised this with managers, who told us the service had not considered the safety aspect of caring for young people on the ward without trained paediatric staff.

We also found that medicines were not effectively managed. We issued the trust with a warning notice which asked them to make improvements in medicines management by 10 January 2020. This was reviewed during our inspection in January 2020 and we will continue to monitor trust progress in relation to this.

Are services effective?

Our rating of effective stayed the same. We rated it as good because:

People have comprehensive assessments of their needs, which include consideration of clinical needs (including pain relief), mental health, physical health and wellbeing.

Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary.

Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.

Staff protected the rights of patients subject to the Mental Health Act 1983.

Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care.

Information about people’s care and treatment, and their outcomes, was routinely collected and monitored. This information was used to improve care.

Managers appraised staff’s work performance and held supervision meetings with them to provide support and development.

However;

The gynaecology service did not make sure staff were competent for their roles. For example 50% of staff had not completed basic life support training at the time of inspection and staff in termination of pregnancy services had not completed sexual health training.

Are services caring?

Our rating of caring stayed the same. We rated it as good because:

The caring domain ratings were good in all core service areas we inspected.

We saw that the trust had a patient centred approach to care.

Patient feedback was positive and response rates were good.

All staff demonstrated a caring and respectful manner when caring for patients and relatives.

Staff included patients and relatives in the decision-making processes of their care. Patients we spoke with said staff treated them well and with kindness.

Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.

Are services responsive?

Our rating of responsive stayed the same. We rated it as good because:

The responsive domain rating for neonatal services was rated good and for maternity was rated outstanding because the services were inclusive and took account of patients and their families’ individual needs and preferences. They coordinated care with other services and providers.

Staff made reasonable adjustments to help patients access services.

The service had 24-hour access to mental health liaison and specialist mental health support (if staff were concerned about a patient’s mental health).

Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients.

Complaints were investigated within the timeframe set out by the trust policy.

However;

Patients could not always access services when needed and receive treatment within agreed timeframes and national targets.

We observed information leaflets available to parents and their families were only supplied in English and it was not clear if they could be obtained in alternative formats. The trust told us leaflets were available in other languages and formats and accessible by the trust website.

Are services well-led?

Our rating of well-led went down. We rated it Requires Improvement because:

Gynaecology services within the hospital were rated requires improvement, due to the lack of governance around processes, in particular training, specifically lifesaving both basic [BLS] and intermediate [ILS] lack consultant support. Leaders within gynaecology service did not always operate effective governance processes, either throughout the service, or with partner organisations. Staff and managers were not always clear about the current performance of the service and plans to improve the quality of the provision offered. All core services at Liverpool Women’s Hospital were rated as good for being well led except for gynaecology services.

Governance around audits and the learning and improvement work lacked leadership and pace. Access and flow through the gynaecology service was an ongoing issue, which had been in place for some time. However, there was an improvement plan in place.

The leadership structure within the gynaecology division was not stable and this had impacted the morale and culture on the wards. As a result, the teams worked in silo and sickness rates were reported as high. Managers were not aware of the concerns we raised relating to young people accessing surgical services, until they were raised at the inspection.

However;

Neonatal services leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients. All staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation and participation in research.

Maternity services leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for women and staff. They supported staff to develop their skills and take on more senior roles. Leaders and staff actively and openly engaged with women, staff, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for women.

Ratings tables

The ratings tables show the ratings overall and for each key question, for each service, hospital and service type, and for the whole trust. They also show the current ratings for services or parts of them not inspected this time. We took all ratings into account in deciding overall ratings. Our decisions on overall ratings also took into account factors including the relative size of services and we used our professional judgement to reach fair and balanced ratings.

Outstanding practice

We found examples of outstanding practice in Liverpool Women’s Hospital NHS Foundation Trust

For more information, see the Outstanding practice section of this report.

Areas for improvement

We found areas for improvement including 16 breaches of legal requirements that the trust must put right. We found 23 things that the trust should improve to comply with a minor breach that did not justify regulatory action, to prevent breaching a legal requirement, or to improve service quality.

For more information, see the Areas for improvement section of this report.

Action we have taken

We issued a warning notice to the trust. Our action related to breaches of five legal requirements at a trust-wide level and across 3 core services.

For more information on action we have taken, see the sections on Areas for improvement and Regulatory action.

What happens next

We will check that the trust takes the necessary action to improve its services. We will continue to monitor the safety and quality of services through our continuing relationship with the trust and our regular inspections.

Outstanding practice

The community maternity service had a dedicated ’Non-English Speaking’ team. Community midwives worked with a local NHS community provider to deliver antenatal classes for women from specific communities. Classes were held in community venues for women from the Polish and Romanian communities in their own language. The service held a multidisciplinary “link” clinic every Monday at staffed by midwives from the non-English speaking team. All non-English speaking women attended this clinic for all their scheduled antenatal care. The “link “clinic was also staffed by interpreters, and social inclusion workers, to provide advocacy, signposting and support for women.

The neonatal service went the extra mile for bereaved families and had introduced an innovative way of creating keepsakes making casts of babies holding hands with their parents and siblings. They had collaborated with a national charity who polished and respectfully presented the casts.

Areas for improvement

Action the trust MUST take is necessary to comply with its legal obligations. Action a trust SHOULD take is to comply with a minor breach that did not justify regulatory action, to prevent it failing to comply with legal requirements in future, or to improve services.

Action the trust MUST take to improve:

  • The trust must ensure the proper and safe management of medicines, including ensuring that there is a robust process in place for the monitoring of emergency medicines stored on the resuscitation trolleys to make sure that medicines do not exceed the manufacturers recommended expiry dates and are safe to use when needed. (Regulation 12 (1) (2) (g)
  • The trust must ensure the equipment used is safe for its intended purpose and ensure all resuscitation equipment is checked regularly and there are appropriate systems to monitor compliance with this. (Regulation 12 (1) (2) (e)
  • The trust must ensure that patients receive care in a timely way and work towards improving performance against national standards such as the time from diagnosis to treatment. Regulation12 (2)
  • The trust must ensure that their systems and processes operate effectively across all areas of the trust to ensure that they assess, monitor and improve the quality and safety of all services provided and assess, monitor and mitigate the risks to the health, safety and welfare of service users and others who may be at risk. Regulation 17 (2) (a and b)
  • The trust must ensure that their audit and governance systems remain effective. Regulation 17 (2)(f)

Neonatal services

  • The trust must ensure the proper and safe management of medicines, including ensuring that there is a robust process in place for the monitoring of emergency medicines stored on the resuscitation trolleys to make sure that medicines do not exceed the manufacturers recommended expiry dates and are safe to use when needed. (Regulation 12 (1)(2)(g)

Maternity services

  • The service must ensure the proper and safe management of medicines, including ensuring that there is a robust process in place for the monitoring of emergency medicines stored on the resuscitation trolleys to make sure that medicines do not exceed the manufacturers recommended expiry dates and are safe to use when needed. (Regulation 12 (1)(2)(g)

Gynaecology services

  • The service must ensure the proper and safe management of medicines, including ensuring that there is a robust process in place for the monitoring of emergency medicines stored on the resuscitation trolleys to make sure that medicines do not exceed the manufacturers recommended expiry dates and are safe to use when needed. (Regulation 12 (1)(2)(g)
  • The service must ensure they have enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment on the ward. Regulation 18(1)(2)(a)
  • The service must ensure that there is a system in place to manage the deterioration of a poorly young person between the age of 16 and 18 years old. Regulation 12(1)(2)(c

We told the service that it should take action either because it was not doing something required by a regulation, or it would be disproportionate to find a breach of the regulation overall.

Neonatal services

  • The service should ensure that cleaning products which are hazardous to health are consistently stored securely to prevent potential risk to patients and visitors in line with national patient safety alert requirements. Regulation 12(2)(b)
  • The service should consider a review of its governance processes for the monitoring of daily resuscitation equipment checks to make sure that equipment is safe and ready for use. Regulation 12(1) (2)(e)
  • The service should ensure that medicines related stationery is stored securely and cannot be accessed by unauthorised persons.
  • The service should consider a review of the monitoring process for the recording of medication storage temperatures so that documentation reflects action staff have taken when temperatures have exceeded the maximum range.
  • The service should consider a review of its guidelines and policies so that expected review dates are clearly visible to staff.
  • The service should consider a review of the information available to parents and their families on the units so that it is clear that it can be requested it in alternative formats or languages to meet their needs.

Gynaecology services

  • The provider should ensure there is appropriate tool to assess pain.
  • The provider should ensure all staff complete their mandatory training and safeguarding training.
  • The provider should ensure they have a vision in place which is underpinned with values and a strategy.
  • The provider should ensure they support the needs of dementia patients or patients with any other protected characteristics.
  • The provider should ensure the leadership structure is stabilised.

Is this organisation well-led?

Our comprehensive inspections of NHS trusts have shown a strong link between the quality of overall management of a trust and the quality of its services. For that reason, we look at the quality of leadership at every level. We also look at how well a trust manages the governance of its services, in other words, how well leaders continually improve the quality of services and safeguard high standards of care by creating an environment for excellence in clinical care to flourish.

Our rating of well-led at the trust went down. We rated well-led as requires improvement because:

Leaders had the skills and abilities to run the service. They understood and managed the long-term priorities and issues the service faced. However not all frontline staff and senior managers we spoke with, were aware of an immediate strategy and vision which covered the trust in the short to medium term.

Managers did not have an effective system in place to check to make sure staff followed internal processes and national guidance.

There was no effective governance process in place for the monitoring of resuscitation equipment checks and some policies and guidelines did not have documented review ‘due’ dates, so it was not clear to staff if a policy had exceeded this.

The leadership structure within the gynaecology division remained unstable and this had impacted the morale and culture on the wards. As a result, the teams worked in silo and sickness levels were high.

Managers were committed to continually learning and improving services. However not all of the managers we spoke with, were able to articulate a good understanding of quality improvement methods and the skills required to use them.

The managers investigated incidents, however lessons learned were not consistently shared within teams and the wider service.

Leaders and teams did not consistently use systems to manage performance effectively. The performance in the gynaecology service particularly required improvement.

However;

The information systems were integrated and secure. Data or notifications were consistently submitted to external organisations as required.

Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients.

Leadership teams had some understanding of the current challenges and pressures impacting on service delivery and patient care.

29 Jan to 28 Feb 2018

During a routine inspection

Our rating of services stayed the same. We rated it them as good because:

  • There were enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff assessed patient risk well. Staff identified risks to patients and took appropriate measures to mitigate these risks.
  • Medicines were prescribed, administered, recorded and stored well. Patients received the right medication at the right dose at the right time.
  • There was an established Maternity Services Liaison Committee (MSLC), which provided an effective channel for users of maternity service to influence the local provision of maternity services.
  • Community staff made prompt and timely referrals for women and babies that were identified as vulnerable and there was evidence that the trust worked closely with the enhanced midwifery team, safeguarding team and social services.
  • Parents were involved in choices about their baby’s birth both at booking and throughout the antenatal period.

However:

  • We found that some governance structures, processes and initiatives were recently developed and had yet to be fully embedded and audited in practice.
  • Staff did not always have prompt access to up-to-date, accurate and comprehensive information on patients’ care and treatment.
  • Managers across the hospital did not always promote a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • Computer information systems needed to be enhanced, streamlined and developed further to reduce and mitigate risks.

18 - 19 February and 4 March 2015

During a routine inspection

Liverpool Women’s Hospital is one of two locations providing care as part of Liverpool Women’s NHS Foundation Trust. This hospital provides a range of specialist services for women including inpatient and community maternity services, which deliver approximately 8,000 babies a year, a neonatal service to support newborn babies needing specialist care, obstetrics, gynaecology, gynaecology oncology, termination of pregnancy and a unique emergency room for patients who have urgent gynaecological problems or women with problems in early pregnancy (at fewer than 16 weeks). The trust is also a major obstetrics, gynaecology and neonatology research hospital, one of only two specialist trusts in the UK, and the largest women’s hospital of its kind in Europe.

Liverpool Women’s NHS Foundation Trust serves more than 30,000 patients from Liverpool, the surrounding areas and across the UK.

We carried out this inspection as part of our comprehensive inspection programme.

We carried out an announced inspection of Liverpool Women’s Hospital on 18 and 19 February 2015. In addition, we undertook an unannounced inspection between 4pm and 7pm on 4 March 2015. As part of the unannounced visit, we looked at maternity and surgical services.

Overall we rated Liverpool Women’s Hospital as good although we found that the Community Maternity Service required improvement. There were plans in place to reconfigure and integrate the community service. The plans had not yet been implemented at the time of our inspection.

Our key findings were as follows:

Overall we found that the hospital provided effective care with outcomes comparable with or above expected standards. Patients were very positive about the care and treatment they received at the hospital.

Staff were positive about the additional investment in midwifery and nursing staff and morale within the hospital had improved as a result.

The senior team was visible and accessible to staff and managers were seen as supportive and approachable. Managers were keen to engage and include staff in service development. There were some concerns raised in relation to the leadership style in the Labour Ward that managers have committed to exploring and addressing.

There was a positive and enthusiastic culture throughout the hospital. Staff were committed and passionate about their work and proud of the services they offered to patients. Staff were keen to learn and continuously improve the services they offered to patients.

Nurse and Midwifery staffing

Nurses and Midwives were caring and compassionate and treated patients and those close to them with dignity and respect. They were committed to giving patients a high standard of care and treatment. Staffing levels were calculated using a recognised tool and regularly reviewed.

Since our last inspection there had been a significant increase in the numbers of nurses and midwives employed and there were sufficient numbers to meet the needs of patients. There were plans in place to increase the number of neonatal nurses to meet the British Association of Perinatal Medicine (BAPM) standards. At the time of the inspection, staffing was sufficient to meet the needs of babies being cared for as current neonatal staff were working extra hours to fill in gaps on the staffing rota.

The neonatal service had introduced the Advanced Neonatal Nurse Practitioner (ANNP) role. The ANNPs were having a positive effect in supporting high quality care for babies requiring specialist neonatal support, however, it was acknowledged that more work was required to fully embed and integrate this key role within the service.

Medical staffing

Medical treatment was delivered by skilled and committed medical staff. There were excellent examples of medical staff providing strong leadership and active engagement in the design and development of services.

There were sufficient numbers of consultants and middle grade doctors to provide good quality care and treatment for patients; however, in maternity – inpatient services, the consultant cover was only 77 hours, which was lower than the 98 hours minimum recommended by the Royal College of Obstetrics and Gynaecology for a unit this size. Junior medical staff were well supported and provided with excellent teaching and learning opportunities.

The tier 1/middle-grade staffing levels were acceptable in terms of establishment but frequently the neonatal unit operated below the establishment. In response to this, the service had introduced an Advanced Neonatal Nurse Practitioner role to help and support junior doctors working in the unit.

Safeguarding

There were robust policies and procedures in place for raising child safeguarding concerns. These processes were supported by staff training. All relevant staff had received appropriate levels of training for safeguarding children.

Staff were aware of the process and demonstrated a good understanding of their role in safeguarding vulnerable children. Interagency working was well developed and there was good communication with relevant professionals in this regard.

Staff training for the safeguarding of vulnerable adults had recently been introduced. Staff were developing their understanding, competency and knowledge in this area at the time of our inspection. Staff training figures indicated that by March 2015 95% of relevant staff would have received Adult safeguarding training.

Safeguarding practice was supported by a trust wide safeguarding team that staff could access for advice and support. However, we did find some examples in the surgical service where the approach to the safeguarding of adults required further development.

There were specialist clinics in place, supported by a Somali health link worker, to identify and address the needs of women who had experienced female genital mutilation (FGM) and designated midwives within the community service to support women whose circumstances had been identified as making them vulnerable.

Incident reporting

There were established systems for reporting incidents and ‘near misses’. Staff had received training and were confident in the use of the incident reporting system. The latest national reporting and learning system (NRLS) data (September 2014) stated that the organisation had a reporting rate of 68.48 per 1000 bed days, which was higher than the median of 35.92 for the cluster of acute specialist trusts. The trust were in the highest 25% of reporters. The trust was however slow to upload incidents to the NRLS system with 50% of incidents submitted more than 41 days after the incident had occurred.

The reporting rates had improved significantly from the previous reporting period. Managers had identified that it was ‘no harm’ and ‘near miss’ incidents that were not being reported appropriately. This was supported by the NRLS report, which highlighted that the percentage of incidents reported by the trust in which no harm had been caused was 51%, compared with 76% across all acute specialist organisations.

There was low incident reporting for all types of incidents in the community maternity service. The trust was working with its staff teams to address this issue and to encourage and support staff to report all incidents appropriately. Managers realised that the poor patient safety incident reporting culture could hinder staff in identifying risks and the trust in taking action to prevent avoidable harm to patients.

There were good examples of learning from incidents. Staff in all clinical areas were able to describe changes in practice following incident investigations. To support learning from Serious Incidents, staff were provided with a one-page summary of the key findings and recommendations to disseminate the learning across their service.

Cleanliness and infection control

There was a visibly high standard of cleanliness throughout the hospital. Staff were aware of current infection prevention and control guidelines and observed good practice. Hygiene audits demonstrated a high level of compliance. There were suitable arrangements for the handling, storage and disposal of clinical waste, including sharps.

Cleaning schedules were in place and displayed throughout the ward areas and departments. There were clearly defined roles and responsibilities for cleaning the environment and cleaning and decontaminating equipment.

Staff were vigilant in managing and preventing infection risks. There were services in the hospital whose practice in infection control was exemplary.

Nutrition and hydration

People were given a choice of suitable and nutritious food and drink, and we observed hot and cold drinks available throughout the day.

Patient’s religious and cultural needs were considered and food was provided in accordance with their requirements. Staff provided appropriate and discreet support for those patients who needed help with eating and drinking.

Specialist dietary support was available to patients whose condition indicated or required a specialist diet.

The hospital had a team of midwives, support workers and infant feeding advisers who helped support women to feed their babies. The hospital team was supported by Liverpool BAMBIS (Babies & Mums Breastfeeding Information and Support), a team of peer supporters who offer breastfeeding support and information to pregnant women, breastfeeding mothers and their families.

Access to services

Services were planned to meet the diverse needs of patients using the hospital and community based service. There were access points designed so that pregnant women without a GP could self-refer. There was a unique gynaecological emergency service that provided immediate support to women who again could self-refer.

A link booking clinic was held at Liverpool Women’s Hospital for women whose first language was not English. The Birth Choices Clinic provided support throughout pregnancy to women with tokophobia (fear of childbirth) and a vaginal birth after caesarean section (VBAC) clinic was also available.

There was a specialist clinic, supported by a Somali health link worker, to identify and address the needs of women who had experienced female genital mutilation (FGM) and designated midwives within the community service to support women whose circumstances had been identified as making them vulnerable.

We saw several areas of outstanding practice including:

  • The implementation of the HeRo system. The neonatal unit was the first in the country to put this system into practice.
  • The neonatal unit’s benchmarking of its practice and outcomes against other units in the UK and the USA.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the hospital must:

  • Improve the way in which medicines are managed and stored.
  • Check the folder of medication data sheets in each room within the neonatal unit at more regular intervals; and confirm with a signature that they have been checked and are valid.
  • Store the portable box containing emergency medicines in the high dependency unit securely.
  • Provide appropriate neonatal resuscitation equipment in the maternity assessment unit.
  • Provide effective controls to prevent the abduction of infants from the labour ward and the Catharine Medical Centre.
  • Ensure that risks regarding the storage of formula milk are appropriately assessed, and effective controls implemented to manage those risks.
  • Provide operating department practitioners or suitably qualified midwives in theatre recovery outside of normal working hours.
  • Ensure that the telephone triage line is staffed at all times.
  • Ensure that, when restraint is necessary, it is undertaken in accordance with the relevant regulations and legislation.
  • Ensure that paper medical records are of an adequate standard and provide an accurate, up-to-date record of the consent, care and treatment provided.
  • Ensure that all staff are able to safeguard adults appropriately.

In addition the hospital should:

  • Review the number of hours of consultant cover in maternity, which were lower than the recommended minimum from the Royal College of Obstetrics and Gynaecology for a unit this size.
  • Ensure that issues identified during audits are addressed.
  • Review the numbers of incidents reported in all services.
  • Ensure that domestic violence referrals from the police are reviewed within agreed timescales.
  • Review practice with regard to the artificial rupture of membranes during induction of labour.
  • Improve the response rates for the NHS Friends and Family Test.
  • Consider including emergency appointments in the induction suite diary.
  • Ensure that there is an effective system in place for testing portable electrical appliances.
  • Allocate a non-executive director with responsibility for termination of pregnancy services.
  • Review the timing of resuscitation decisions so that discussions are initiated with patients at a time when they are well enough to fully consider their wishes.
  • Initiate work on advanced care planning with patients at a time when they are well enough to fully consider their wishes.
  • Monitor the quality of care planning on the wards against patients’ assessed needs.
  • Provide dementia training for ward staff.
  • Address the leadership issues and staff morale within the intrapartum areas.
  • Address the role of the advanced neo-natal practitioners (ANNPs) so they are clear where their role sits and take steps to involve them in developments in the neonatal service.
  • Consider the provision of newborn life support training for community Midwives.
  • Consider auditing the availability of patient records.

Professor Sir Mike Richards

Chief Inspector of Hospitals

30 September 2014

During an inspection looking at part of the service

We had previously inspected this service on 9 April 2014. During this inspection we found there had been significant improvements in the areas of non-compliance at Liverpool Women's Hospital since our last visit. The inspection focused on the maternity unit as this was where the previous areas of non-compliance had been identified.

We spoke with 11 women about their experience of receiving care and support at Liverpool Women's Hospital. Everyone spoke very positively about their experiences at the hospital. Comments included:

'They really look after you well here',

'The Women's is the best place to have a baby'.

During this inspection we spoke individually with 14 midwives. We also spoke with the members of the executive team with responsibility for implementing the trust action plan formulated to address the areas of non-compliance identified at our last inspection.

Staffing levels had improved significantly within areas of the hospital providing intrapartum care (care during childbirth), which had led to improvements in the experience for patients. However midwives had been regularly moved from the principal post natal ward to areas providing intrapartum care during busy periods, leaving the post natal ward short of midwives.

Complaints were well managed within Liverpool Women's Hospital. Considerable improvements had been made to the way risks and quality were managed within the trust but there was still further development needed to the way in which the organisation investigated serious incidents and learned from incidents and complaints.

9 April 2014

During an inspection looking at part of the service

We had previously inspected this service on 7 and 8 July 2013. During this inspection we found there had been some improvements in how women and their babies were cared for and in how staff were supported. However, there were other areas where the trust failed to meet essential standards of quality and safety. Part of this inspection was undertaken outside of normal working hours. We started the inspection at 6am to see how women and their babies were cared for during the night shift.

We spoke with ten women and four relatives during our inspection who all spoke positively about their experiences at the hospital. Their comments included:

'It has been brilliant; they told you what was happening,"

'There are no words to describe how grateful we are,'

'They made my stay a happy one,'

'They explained everything to me.'

Staff at all levels were better supported to undertake their roles through training and appraisal, and staff morale throughout much of the maternity directorate had improved. However, maternity staffing levels were still sometimes inadequate, which meant that the trust was not always able to provide safe and effective intrapartum (care during childbirth) and post natal care to women and their babies.

There were systems in place to assess risk and quality within the trust, but the quality of these systems was not adequately managing risks to staff and patients. Improvements were also needed in the way in which the trust handled complaints.

7, 8 July 2013

During an inspection in response to concerns

We carried out a responsive inspection of Liverpool Women's Hospital as a result of us receiving a number of concerns about the service including a concern about staffing levels on the maternity unit and the impact of this on women's and their babies experiences of the service.

We arrived at the service unannounced at 6pm on Sunday 7 July 2013 and we returned the following day to continue the inspection.

During the visit we spoke with women across the maternity service and with their partners and relatives. This included the postnatal ward, labour ward, the midwifery led unit and the triage and assessment unit. The feedback we received from the majority of women and relatives was very positive and people in the main described good experiences and good outcomes from their stay or visit.

People described the care and treatment they had received as 'excellent', 'brilliant' and they described staff as 'amazing' and 'approachable'. People felt safe and confident in the ability and experience of the staff supporting them.

However, people did also tell us that they felt the staff were 'too busy' and 'very busy' and they felt that this prevented them from asking for too much support.

We found concerns about staffing levels throughout the maternity unit. This was evident through our discussions with women who were using the service, from discussions with staff at all levels and from other information which suggested the staffing levels had been a cause of concern for some time. We found the staffing levels had a direct impact on some aspects of women's care and welfare and on how staff were being supported.

Senior managers were aware of the concerns about staffing levels and had been actively trying to address the problems we found prior to our visit. They shared information with us about the actions they had taken to date to reduce the risks associated with reduced staffing levels and to prevent future recurrence of staff shortages.

19 February 2013

During a routine inspection

Patients told us they felt fully involved in making decisions about their care and treatment throughout their stay.

Patients gave us good feedback about their experiences at the hospital. Their comments included;

'We can't fault them, they have looked after us from start to finish'.

'I had a very nice midwife who took care of me'.

'It has been brilliant, we have had a good experience here'.

'I was close to giving up the breast feeding but they got me through it'.

'I would give the service ten out of ten'.

'Midwives have been amazing, I couldn't have coped without them'

We found patients were protected against the risks associated with medicines because arrangements were in place to manage medication safely.

Patients were cared for and treated by staff who had undergone appropriate pre employment checks, in line with NHS employment requirements, before they started working at the hospital.

Overall patients gave us good feedback about the support they had received from staff and staff told us they felt sufficiently trained to meet their roles and responsibilities.

A complaints procedure was in place which enabled patients, carers and visitors to complain if they were dissatisfied with the care or treatment they had received. Systems were in place to monitor all concerns and complaints and to ensure learning took place from these.

16 July 2012

During an inspection looking at part of the service

We spoke with 13 patients about the care they received and how their medicines were handled.

One patient said ' I had been in pain at one point and the staff brought effective pain relief immediately'. Another said I got my pain relief 'as soon as I asked for it'.

A patient told us 'they missed my painkillers once but I rang my bell and they came right away'. Another said their pain was not fully controlled and expressed frustration that the medicines they were prescribed were not fully effective.

We spoke with seven patients about patient controlled analgesia (This is when patients can self inject a pain reliever using a special device). All said they were provided with detailed information about what it was and how to safely manage it.

One patient told us about their take home medicines and said they had been handled properly. Another told us nursing staff had explained what all her medicines were for and how to take them.

A patient told us 'my medicine had recently been changed to an injection and staff clearly explained to me why this had been done'.

20 March and 30 May 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

7 February 2012

During a routine inspection

We asked people using the service to tell us about how well staff explained their care, treatment and support choices to them. We asked questions such as whether people felt they had been given enough information and choice about their treatment, if pain relief had been discussed and if they had been given information about their recovery.

The feedback we received from people was very positive. People told us that they had been fully involved in decisions about their care and treatment throughout their stay and they felt confident to ask staff questions about their treatment. People's comments included the following;

'Staff have spent a lot of time explaining things and have encouraged me and my husband to ask questions'.

'I have asked lots of questions and they have always been answered'.

'I had a birth plan that I was involved in'.

'I can't fault how I have been treated. It has been exceptional, I feel staff communicated everything I needed to know'.

'I was given a lot of information about the procedure and what to expect following it'.

'They have been completely open and honest and they have listened to me".

'I've talked with staff about how the birth might be. I've been given information about birth and pain relief".

People overwhelmingly told us that they felt included and involved in decisions about their care. However, a small number of maternity patients said that they did not feel that they had the opportunity to discuss birthing options and pain relief prior to their admission as part of their antenatal appointments. They did however tell us that they had been given written information on birth and pain relief.

We spoke with a number of patients and their relatives about their experience of care, support and treatment across the wards we visited. We asked people a variety of questions including questions about their comfort, pain relief, privacy and dignity, and if they felt safe. We also asked people to tell us their overall view of the quality of the service they were receiving. Every person we spoke with made positive comments about the care and treatment they received and we did not receive any negative comments. People's comments included the following;

'I would give them ten out of ten. Everything has been brilliant. I couldn't have asked for more. Anything I wanted I could get, staff have checked on me constantly and never left me alone it's been superb really'

'They discussed my plan of care with me'.

"It's been brilliant"

"Staff have supported me with my baby and helped me to feed her and settle her".

"I had a midwife with me all of the time. They were brilliant with me and my partner"

"I couldn't fault the care I've had".

"I've had pain relief when I've needed it and they have helped me when I've not felt so well".

We asked patients if they felt safe during their stay and they told us that they did. One person said 'I definitely feel safe'. Another person told us 'Yes, I feel very safe'.

People told us that they would feel confident about telling someone if they were worried about their own safety or the safety of another patient. One person commented, 'I would tell somebody if I didn't feel safe or if I thought another patient felt that way'.

We asked people who were using the service a range of questions about the staff. We asked people to tell us if staff responded to them in an appropriate and timely manner, whether or not they felt confident in the skills and knowledge of the staff team and whether staff were meeting their needs. Each of the people we spoke with gave us very positive feedback about staff. They told us that staff responded to them quickly when they were needed and that staff appeared well trained and competent. People's comments included the following;

'I can't fault the staff they have been absolutely fantastic'.

'All the nurses have been brilliant'.

'They have gone the extra mile'.

'One of the nurses sat with me and reassured me for much longer than I expected'.