CQC State of Care Report 2022/3
The Care Quality Commission produce an annual assessment of healthcare and social care in England each year. The 2022/2023 report was published on 20 October 2023, with a purpose of looking at trends, sharing examples of good and outstanding care and highlighting where Health and Social care needs to improve.
The report describes this year as being a turbulent one for health and social care, quoting examples of ‘gridlocked’ care and the cost of living biting harder for the public, staff and providers. Workforce pressures have therefore been escalated.
Part of the report focuses on maternity services and the CQC has continued its programme of maternity inspections, having revisited 73% of maternity services in NHS acute hospitals.
The CQC found:
- 10% of maternity services have been rated as inadequate overall;
- 39% require improvement with safety and leadership remaining of particular concern;
- 15% of services are rated as inadequate for safety; and
- 12% of services are rated as inadequate for being well lead.
Leadership
The report emphasises the need for strong maternity leadership with a team that works well together. The findings included concerns around governance and lack of oversight from boards, including challenges in identifying issues of packages of support at service delivery level. The CQC also found problematic working relationships between service level managers and neonatal, midwifery and obstetric leaders.
It also found examples of good practice and identified improvements where there was clearly defined management and leadership structures and teams worked well together benchmarking performance.
Staffing issues
Safe staffing levels remain to be a continuing challenge for maternity services and the CQC reported that they had seen examples of significant staffing issues in the Trusts that they had visited. That included high vacancy rates and also lower staffing levels which impacted on the implementation of the recommendations in the Ockenden report.
On the issue of consultant led care, it stated: “There must be a minimum of twice daily consultant lead ward rounds and night shifts of each 24-hour period. The ward round must include the labour ward coordinator and must be multidisciplinary. In addition, the labour ward should have regular safety huddles and multidisciplinary handovers and in-situ simulation training."
The CQC found that the majority of units were achieving this recommendation at the moment, however there were concerns that it was often fragile and relied upon every consultant to be available, supporting the need for further training of doctors and midwives to work in maternity services.
The lack of staff had also impacted on care after birth, with one woman stating that after her surgery, she was “very tired, stressed and overwhelmed and only two midwives in the 10 or 15 I had were empathetic and properly took time to care for me and help me."
Post Ockenden, the Health and Social Care committee published a report in July 2022 stressing the urgent need for a robust and funded maternity wide workforce plan to be delivered without delay.
Communication
The 2022 Maternity Survey showed that 59% of women and other people using maternity services were given information and explanation during their time in hospital. Recent research from Healthwatch supported a key concern identified for mothers was that miscommunication about their care could lead to inappropriate consent being given for treatment where a patient does not fully understand what is being offered.
The CQC found a range of differences in the midwives working in maternity services from firmly reassuring, comforting and helpful, to rude, unhelpful, discouraging, and them being inconsiderate of individuals feelings.
Health inequalities in maternity care
The report still expresses concerns of the higher infant mortality in the black and Asian ethnic groups in comparison with the white ethnic groups, quoting the Nuffield Trust survey 2021 data which quoted the following differences in outcomes:
- Black ethnic group - 6.6 deaths per thousand live births;
- Asian ethnic group - 4.8 deaths per thousand live births; and
- White ethnic group - three deaths per thousand live births.
In order to understand the cause of inequalities in maternity care, the Care Quality Commission in July 2023 commissioned research interviewing midwives from ethnic minority groups. They identified that language and communication where people had poor English, or no English, was associated with worse experiences of maternity care. It also reported that there were circumstances where a patient was nodding to suggest they understood, however no attempt was made to clarify their understanding and that there was a reluctance to call translators to support care decisions.
There was also feedback that there were still racial stereotypes directed towards the women using the services, including the use of inappropriate language such as black women are more ‘aggressive’ and racially stereotyping terms such as ‘princess’ used in the context of Asian women.
The interviewees reported misconceptions around ethnic minorities using maternity services such as not needing pain relief if they were from a certain ethnic background.
Midwives also reported back there was a lack of knowledge or interest in conditions which were more likely to affect ethnic minority groups.
It was further worrying that interviewees highlighted that a patient’s negative experiences in maternity care could lead to them not attending follow-up appointments or seeking follow-up care when it was needed, which could increase risk to the patient or baby.
Future actions
As a result of the research, the following actions were suggested to support change for people using maternity services:
- Channels for staff and people using services to feel safe in reporting inequitable care, such as networks and groups, and approachable senior people with accountability;
- More availability and use of translation services and interpreters to help people who do not speak English to navigate their care;
- Increasing the knowledge of staff about cultural practices and traditions, to address misconceptions and misunderstanding and to tackle unconscious bias; and
- Outreach and engagement with ethnic minority communities, to better understand the needs and concerns of people using maternity services and how services can be better orientated to these.
The report concluded there had been increased demand and pressure on staff which is impacting on their wellbeing, and that many people are still not receiving the quality of maternity care they should be able to expect. There are also ongoing concerns around leadership, staffing communication, inequalities and the impact on people from ethnic minority groups.
Recent investigations
In recent years we have seen investigations into maternity services at Morecombe Bay, Shrewsbury and Telford, East Kent and a review is currently being undertaken at Nottingham University Hospitals NHS Trust.
Families are calling for a nationwide inquiry following the deaths of their babies to examine what they consider a system wide problem. The Maternity Safety Alliance says that “despite a raft of national initiatives and policies implemented in the wake of investigations and reports, systemic issues continue to adversely impact on the care of women and babies."
After reading this report, clearly so much more needs to be done to provide a safe maternity environment. Over the last 30 years, I've been working in this field and, as a medical negligence lawyer, I've represented hundreds of families living with the consequences of defective care where mothers or babies have lost their life or where mother or baby has suffered life-changing injuries. They're now calling for an investigation across England in the wake of repeated maternity scandals.
While the Department of Health is investing more money into maternity services and training of new staff, so much more needs to be done to create cohesive teams that are well led and delivering consistent services across the country.
Irwin Mitchell is supporting families who have been impacted by maternity failings. Find out more about our expertise in supporting families at our dedicated medical negligence section.
