Agenda item

To receive a report on the progress of the delivery of the Northwick Park NHS Trust Maternity Improvement Plan.

Lisa Knight (Chief Nurse, London North West University Healthcare NHS Trust (LNWUHT)) introduced the item, advising that the Maternity Ward at Northwick Park Hospital had been upgraded by the CQC from ‘inadequate’ to ‘requires improvement’. The report included some caveats, and as an organisation it was recognised that work was needed to embed the improvements undertaken and ensure they became business as usual. She highlighted that cultural changes took time, and small improvements were being made daily in relation to cultural behaviours, but that remained the more fragile element of the work being done. The ward continued to be supported by the Local Maternity and Neo-Natal System (LMNS) and the Director of Midwifery from Chelsea and Westminster. There was also a National Maternity Improvement Programme looking at all maternity units in the country to support improvement, with the Trust being visited twice so far as part of their diagnostics. The Trust were also working with Healthwatch around how the diversity and representation on the Maternity Voices Partnership could be improved.

In relation to recruitment of midwives, the Committee were advised that this particular risk still existed and was a big challenge. The number of vacancies had reduced since the Trust last reported at the Committee, from 46 to 40 midwifery vacancies, which was not a significant improvement. The Committee heard that the Trust had expected this and other units struggled in the same way. There was a comprehensive recruitment plan in place to address this issue and the rate of leavers had slowed which was positive. Nine international midwives were starting in May 2022 as part of the Capital Midwife Programme.

In relation to leadership and structure, Lisa Knight advised that they had appointed into the substantive posts of Director of Midwifery, and Director of Operations for Women’s and Children, meaning that the divisional leadership team was now substantive and the Trust were pleased with that.

The Chair thanked Lisa Knight for her introduction and invited comments and questions from those present, with the following issues raised:

The Committee queried the meaning of Table 2, under paragraph 3.1, in terms of what the actions referred to. They were advised that the CQC had 3 layers of action which were; enforcement actions, ‘must dos’, and ‘should dos’. At the time of the report there were 16 ‘should do’ actions, 4 of which had been completed. The Trust had set themselves a timeline for when they expected to achieve the ‘should do’ actions, and were discussing those timescales with the Board. For example, the recommendation ‘the Trust should ensure there are enough midwifery staff with the right qualifications, skills, training and experience’ was not in a position to be completed immediately and there was a long lead time associated with that particular action. Many of the ‘should do’ actions were longer term. The shorter term actions had been completed and the Trust were now moving into the medium and longer term actions, some of which had a lead time of 6 months or longer. Pippa Nightingale (Chief Executive, LNWUHT) added that the team had a good grip on the detail, and it was a long journey. The Trust were mindful that the maternity service had been in a similar position previously and were not interested in quick fixes but sustainable cultural change.

It was confirmed that Health Education England had removed the ruling that the site was unsuitable for placing students, and students would be coming back on site from next month.

In relation to the preceptorship programme and the pathway for midwifery qualification, the Committee noted that this had been raised as an issue in the previous report to the Committee. They queried what improvements had been made for new graduates who hoped to become midwives. Lisa Knight advised that the Trust had spent a lot of time with the preceptorship midwives and had collaborated with an External Preceptorship Speciality Team from Nursing to review the programme with the Midwifery Team. There was now a more balanced preceptorship programme where, as well as competency based work, there was the opportunity to undertake reflective practice and restorative supervision, which had made a difference. Health Education England had evaluated the experience of the preceptorship midwives at the end of 2021 and were happy with their experience and therefore would not be reviewing it again. There was no backlog of staff waiting to move from a Band 5 to Band 6, and as soon as competencies were met staff automatically transferred into Band 6, with the majority of midwives occupying a Band 6 role.

In relation to the monitoring of staff, the Committee were advised that demographics of the preceptorship programme and cultural behaviours were monitored as a whole organisation looking at Band 5 to 6 but also the lower bandings. Work plans were in place to monitor the progress improvements in that area.

The Committee noted that the improvement plan was long term, however wanted to reassure residents that the service was safe now. Pippa Nightingale endorsed the messages and confirmed that the service was now safe and the Trust had done all it could to make sure the clinical pathways were safe. Previously the Trust had seen women getting lost along the maternity pathway, for example due to language barriers, which had in some cases resulted in stillbirth, but those processes had been tightened up and improved to ensure a safe service. As services were now safe, the Trust had an opportunity to breath and re-establish where it would go next in terms of the very important strategic work needed for maternity services. That was needed to be done in collaboration with stakeholders and service users, looking at what an outstanding maternity service might look like for the Brent population. That engagement piece was now ready to start. In addition, internal improvements were being worked on with the multi-disciplinary team.

Noting that maternity services had previously moved up and down with CQC ratings, the Committee queried what would be different now to previous improvement plans. Lisa Knight advised that there was now an infrastructure built in to the maternity unit to deliver the improvement plan, with a very senior Audit Midwife in place to audit compliance against standards and safety on a day by day basis. That midwife looked at safety daily and reported back so that everybody had visibility on that. Lisa Knight had bi-weekly Maternity Steering Group meetings, and the Maternity Improvement Group, chaired by the Chief Executive, was embedded into the governance structure. Work on the ground had been done to build a team that would keep the service safe moving forward and keep a close eye on metrics. Pippa Nightingale was confident that the Trust would be able to move the maternity service from ‘requires improvement’ to ‘good’ within a year, and then to ‘outstanding’ within a year of a ‘good’ rating. She highlighted that the Trust had no control over when it was inspected and visits were unannounced.

The Committee asked how infant mortality rates were improving. They were advised that the perinatal mortality rate was within the acceptable range for the year. The Trust was compliant with its Duty of Candour, which was a monitored process, and were not an outlier when compared across London for serious incidents in the past 12 months. With the cultural work done, staff were reporting clinical incidents which were not resulting in serious incidents any higher than any other unit. Quarterly meetings with the Health Services Investigation Branch were held where they reviewed perinatal mortality and they had been happy with where the Trust were and felt it was where they would expect it to be for the reporting year. Cases were reviewed on a quarterly basis and individual investigations into maternity cases were undertaken by the Investigation Branch, who then provided the Trust with a slide pack to share their learning from investigations. Feedback from those learnings had showcased that one of the biggest challenges was communication with women with English as a second language. As a result, the Trust had worked hard to improve that aspect of the pathway, including commissioning a new interpretation company and new telephones. At the most recent Maternity Safety Champions meeting they had spent the majority of the meeting discussing how that area could be improved further as it was a complex area. Other methods of disseminating learning from maternity cases included slide packs, monthly governance meetings, monthly learning newsletters and bi-weekly engagement events.

The Chair thanked health colleagues for their responses, and drew the item to a close. He invited members of the Committee to make recommendations, with the following RESOLVED:

The following information requests were made:

i)      That the Committee received a progress report in a years’ time on the progress made in delivering the Maternity Improvement Plan

ii)     That the Committee receives information on the progress made in addressing the recommendations made to London North West University Healthcare NHS Trust by the Community and Wellbeing Scrutiny Committee on 23 August 2021