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CQC says Horton maternity service puts women and babies at risk
08/03/2024
The unit has been rated as “needs improvement”
The maternity unit at the Horton General Hospital has been rated as “needs improvement” by the Care Quality Commission.
The service, which now operates as a midwife led birthing unit, was found at times to be putting women and babies at risk, sometimes using medicines not stored at the correct temperatures and having policies which were difficult for staff to follow.
The Care Quality Commission gave the Oxford University Hospitals Trust two days notice of its visit on October 23 last year.
In a report published today they highlighted these areas of concern:
- Safety checks were not carried out effectively, putting women and birthing people at risk of use of out-of-date equipment. Medicines were not always stored within the required temperature range.
- Staff did not always assess risks to women, birthing people, and babies, as the required risk assessments were not always completed so they could act to remove or minimise any identified risks.
- Although staff had access to policies, procedures and guidelines, some policies were difficult to follow and had not always been updated to reflect changes in linked policies.
- Systems to manage performance were not always used effectively. Relevant risks and issues were not always identified so that action could be taken to reduce their impact.
- 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 provided at the midwifery led unit.
Carolyn Jenkinson, CQC’s deputy director of secondary and specialist care said: “When we inspected maternity services at Horton General Hospital we found a service with poor governance and ineffective systems and processes which meant women, people using the service and their babies could be put at risk of harm.
“We found examples of poor record-keeping, and people using the service weren’t always being risk assessed. The midwife-led unit used a national tool to assess whether someone giving birth was at risk of deteriorating, but staff weren’t always completing these records and leaders didn’t audit them. This lack of oversight meant leaders weren’t always able to identify issues or make improvements when issues were found.
“It was also concerning that safety equipment wasn’t always checked regularly, which meant some out-of-date equipment and products might be used on people. We found a blood giving set which had expired several months before the inspection, and an ambulance transfer bag with expired items inside. This could put women, people using the service and their babies at risk of harm.”
The Horton General Hospital is run by the Oxford University Hospitals Trust. Following news of the inspector’s findings Milica Redfearn, Director of Midwifery with the Trust, said: “We are disappointed by this result but we always welcome feedback on ways to improve our services and we will work with staff, women, and birthing people to make the improvements suggested. We have a great team at the Horton Midwifery-led Unit as the inspectors found when they visited.”
The inspectors did note that “the service engaged well with women and birthing people and the community to plan and manage services”, that there were enough staff, and that the unit kept women and birthing people safe.
Professor Meghana Pandit, Chief Executive Officer at Oxford University Hospitals, said: “As a learning organisation we will improve services along the lines highlighted in the report, although I am disappointed for the staff who have been working so hard to make improvements already.
“I want to be very clear that our commitment to the Horton General Hospital is unwavering, and although this new rating is a setback, we are immensely proud of our local hospital, the services it provides, and our wonderful staff. Our plans for the Horton as a modern district general hospital providing urgent and local care to the people of Banbury and surrounding areas are set out in our Clinical Strategy.
“Over recent years we have increased the capacity of the Brodey Centre, increased our ability to diagnose locally with the installation of a new CT scanner and a new blood testing service, increased specialist input to outpatient clinics such as more obstetrician-led clinics, and increased surgical and day case capacity. All of these improvements are designed to improve access to care locally for the people of Banbury and surrounding areas.”
Published: by Banbury FM Newsteam