The Care Quality Commission (CQC) has told Salisbury NHS
Foundation Trust that improvements need to be made in its
maternity and spinal services following a recent inspection at
Salisbury District Hospital.
CQC carried out an unannounced, focused inspection of the
maternity and spinal services on 31 March, after receiving
information of concern regarding the safety, quality and
leadership of the services.
Following the inspection, the overall rating of the maternity
service moves from good to requires improvement. The rating for
how well-led the service is also moves down, from good to
inadequate. The rating for safe remains requires improvement. CQC
inspected whether services were caring and effective but did not
rate these domains.
The Duke of Cornwall Spinal Treatment Centre specialises in the
management of patients affected by spinal cord injury or disease.
Following the inspection, the overall rating of the service did
not change, and remains requires improvement. The rating for
well-led moves from good to requires improvement. The safe domain
remains requires improvement.
Amanda Williams, CQC’s head of hospital
inspection, said:
“Following our recent inspection of Salisbury District Hospital’s
maternity services, we found that women and babies using the
service received effective care and treatment which met their
needs most of the time. But most of the time is not good enough.
“We have told the trust it must ensure there are effective
systems in place to improve the quality and safety of the
maternity service, and that risks are regularly assessed,
monitored and mitigated to keep people safe.
“We were concerned about the leadership of the service, and the
lack of systems in place to ensure that people were receiving
good care. We also wanted to follow up on previous concerns we
had about the overall culture of the maternity service which
meant that staff were worried about being blamed for incidents
that occurred. Because of this, there had been a reluctance to
speak out, when staff should be encouraged to report incidents
and share learnings, so that improvements can be made. This in
turn had an impact on the safety of the service for patients.
Although the trust had taken steps to address this, there was
still more work to be done.
“We have told the trust that it needs to make significant
improvements in these areas. If sufficient improvements are not
made rapidly, we will consider what further action to take.
“In the Duke of Cornwall Spinal Treatment Centre, we told the
trust that it needed to review governance arrangements, including
regular audits, to make sure improvements were consistently being
made at the service. We also told the trust that risk
assessments, with supporting documentation, must be completed for
each patient in order to keep them safe.
“We will keep both services under review and will re-inspect to
check that improvements have been made.”
In the maternity service, inspectors found:
- The arrangements for governance and performance management
were not clear and did not operate effectively. This meant that
systems were not used to manage performance, identify and manage
risks and review staffing in line with national guidance.
- Safety concerns were not consistently identified or addressed
quickly enough. The service had previously identified a culture
of blame around incident reporting that leaders were working to
improve. However, this was happening too slowly and there was
little evidence of learning from incidents leading to
improvements in safety.
Inspectors found the following in the spinal service:
- During periods of the COVID-19 pandemic, there had been a
lack of leadership due to absence and changes in the divisional
structure which were still being embedded.
- Leaders did not always operate effective governance
processes. Staff were not always able to contribute to
decision-making to help avoid compromising the quality of care.
- Leaders and teams used systems to manage performance, but
these were not always effective.
- The service did not always have enough nursing staff and
allied health professionals with the right qualifications,
skills, training and experience to keep patients safe and to
provide the right care and treatment. Insufficient staffing
levels sometimes impacted on the responsiveness of the service to
meet individual needs.
- Staff did not always complete and update risk assessments for
each patient to minimise risks, and they did not always identify
and act quickly when a patient was at risk of deterioration.
- Staff did not always keep detailed records of patients’ care
and treatment. Some records were incomplete and inconsistent,
although they were stored securely and available to all staff
providing care.
The report will be published on the website on Friday 9 July.
