The Care Quality Commission highlights significant progress needed to improve the quality and safety of maternity services in England 

The Care Quality Commission (CQC) – which inspects NHS services and gives gradings and recommendations for improvement – has today published a review of maternity services in England, based on 131 inspections from April 2022 to December 2023.  

As always, our thoughts are with the families affected by these findings. Baby Lifeline continues to work with NHS maternity services to improve safety and make care better.  

What does the report conclude? 

The report highlights many examples of good care and effective systems, and acknowledges that “every member of staff working in a maternity service wants to provide safe, high-quality care.” It identifies examples of good communication, information sharing and quality improvement, which make a significant impact on women and families’ experiences of maternity care. 

Nevertheless, the report highlights significant opportunities for improvement across maternity services, with almost half being rated “requires improvement” or “inadequate.” Just under half have been rated “good”, and only 4% as “outstanding.” 

The CQC’s key concern is the safety of maternity services. No maternity services were rated as “outstanding” for being safe, and almost two-thirds were rated as “requires improvement” or “inadequate.” There were significant national variations in key areas such as learning from harm, assessing risk, and data collection. 

Overall, the report highlights many factors for improvement and standardisation, and includes best practice examples for trusts to consider alongside national initiatives targeted at improving the highlighted issues. There is a lot of good work happening, and we need to replicate that. 

We are confident that, with the right support from the government, maternity services can make improvements and become safer and better for everyone. The appetite for change is certainly there; we meet thousands of health professionals every year and they all want to provide the safest, best care for the women, birthing people and babies that they look after. 

 

Key findings and opportunities to improve 

The report identifies significant opportunities to improve care, many of which would be significantly supported by investing in staff through training. This mirrors Baby Lifeline’s Mind the Gap research, which found that there were detrimental gaps in training which related to the central causes of harm and death in maternity care. The barriers related to lack of resource: equipment, staffing, and rooms for training.  

The themes of the CQC report include: 

Triage  

The report identified inconsistencies in maternity triage services nationally, with different areas offering differing advice. The report also found many instances where triage phones were not answered in a timely manner, leading to inappropriate delays in assessment. Last year, the Royal College of Obstetricians and Gynaecologists published a best practice guide, which should help to improve this service.  

However, there were concerns around staff training and competence: sometimes the people working on triage had not had the appropriate training due to staffing issues. Nevertheless, the report did find areas of good practice, and concluded that triage wait times and compliance with guidelines were better in services where leaders supported triage-specific staff training. 

 

Staff recruitment and retention 

The report highlights that “chronic issues” around staff recruitment and retention significantly impact on the care women receive. Though the Health and Social Care Act specifies that staff must be supported with appropriate levels of training, the CQC found many areas where this was not the case. Sometimes staff struggled to keep up to date with mandatory training due to rota issues, or were expected to attend essential training in their own time.  

This is echoed in our Mind the Gap research:  

• Fewer than half (43%) of organisations we surveyed in the financial year 2020-2021 reported that most (over 90%) of all staff attended mandatory training/updates, and there was significant national variation in training attendance 

• Nearly three quarters (72%) of organisations told us that staffing was a barrier to providing training. This was not just related to the pandemic: in our 2018 report, the numbers were similar (74%). 

The CQC report also points out that the wellbeing of staff must be considered to address issues with staff retention and recruitment. 

 

Estates and environment  

A common safety concern is the hospitals themselves, with many maternity units lacking space, facilities and equipment including bereavement provision. This is a key barrier to providing high quality care. 

In a recent survey carried out by Baby Lifeline, two-thirds of health professionals told us that equipment on their units was either broken or unavailable when they needed them, which caused delays to providing essential, time-sensitive care. This was often simple, inexpensive – but essential – items such as thermometers and fetal monitoring leads. 

Several women explained to the CQC how the lack of space on wards affected their experiences:  

“After my emergency c-section the ward was full. I was freezing from the operation and me and my baby were wheeled into a storage closet with air conditioning blasting. My baby then became cold and unwell and needed to be put under a lamp once we got into the ward… I became deeply distressed and wanted to leave.” 

 

Inequalities and racism 

The report identifies inequalities and racism as a key safety risk to patients. This is something that is highlighted in a multitude of reports published in recent years. 

The CQC praise some trusts for taking action to reduce the impact of inequalities, including mental health support, support for women living in poverty, and increased awareness and inclusion of diversity. However, the report also found many opportunities for improvement and much inconsistency, particularly with regard to understanding the needs of the local population and the collection and use of demographic data. 

Women, families, and staff also experienced discrimination: 

“My summary is, if you are White you will get good care. If you are not White but you speak English, it’s OK, you will get what you need. If you have poor English – it’s going to be the very basic standard.” 

 

Communication with women and families  

Not being listened to is a key issue highlighted by women and families in the report. This is supported by a five-year downward trend in respondents to the CQC Maternity Survey reporting that they were “always” given the information and explanations they needed. This year, less than two-thirds (60%) of respondents said that they were always given this information. 

Today’s report shows that lack of communication can negatively impact on women’s experiences of birth; they need to be given all of the information they need, in a way that they understand it. 

Furthermore, medical complications such as shoulder dystocia or postpartum haemorrhage can be deeply traumatic for women and birthing people. Enabling them to understand what has happened is essential for their recovery, and can impact on future pregnancies. The importance of compassion and a timely debrief cannot be underestimated. 

“Staff need to be very mindful that you will get people nodding their head but not understanding. And instead of just choosing to accept that, staff need to make sure that they have understood.” 

Privacy, dignity and hygiene concerns were also raised by women in the report; this was linked directly to staffing issues and lack of resource. 

“No-one changed the mat on my bed for hours which was soaked in blood, plus no-one changed my sanitary pad at all the whole time I was there. So my husband had to change it, which shouldn’t really happen.” 

 

Key safety issues include compliance with training requirements 

The report highlights key safety issues including compliance with training requirements (such as measuring babies’ heart rates and safeguarding), identifying and managing risk of deterioration in women and babies, and incorrectly reporting and grading patient safety incidents. Not only are these are missed opportunities for learning, they also compound harm as women potentially do not receive the care they need after birth (for example, if a major haemorrhage is not categorised as such).  

The implementation of the new Patient Safety Incident Response Framework (PSIRF) will hopefully help to address this, but it is also a culture issue. 

 

Training and safety 

Though errors associated with the recognition of risk are amongst the most frequently occurring themes in reports which investigate deaths and injuries for babies and mothers, our Mind the Gap research found clear gaps in training in these areas: 

• Training relating to ‘Early recognition and management of the acutely unwell woman’ was provided by almost 9 out of 10 organisations that we spoke to (89%), and it was mandatory training in over 8 out of 10 (82%) organisations. However, training in recognising and managing the major causes of maternal death (including cardiac disease, thromboembolism, epilepsy and stroke) was patchy, and by no means universally provided. 

• Training relating to ‘Ongoing antenatal and peripartum risk assessment’ was provided by fewer organisations (44%), and ‘Recognition of women at high risk of preterm birth’ was provided by around one third (34%).  

• Training related to ‘Learning from adverse events’ was considered mandatory for some or all maternity staff in just over one third (38%) of organisations.  

Baby Lifeline has been advocating for upskilling staff for four decades. We know that staff want to do the absolute best for the families they look after, but can only do this with proper support and investment.