We had previously inspected this service on 9 April 2014. During this inspection we found there had been significant improvements in the areas of non-compliance at Liverpool Women’s Hospital since our last visit. The inspection focused on the maternity unit as this was where the previous areas of non-compliance had been identified.

We spoke with 11 women about their experience of receiving care and support at Liverpool Women’s Hospital. Everyone spoke very positively about their experiences at the hospital. Comments included:

“They really look after you well here”,

“The Women’s is the best place to have a baby”.

During this inspection we spoke individually with 14 midwives. We also spoke with the members of the executive team with responsibility for implementing the trust action plan formulated to address the areas of non-compliance identified at our last inspection.

Staffing levels had improved significantly within areas of the hospital providing intrapartum care (care during childbirth), which had led to improvements in the experience for patients. However midwives had been regularly moved from the principal post natal ward to areas providing intrapartum care during busy periods, leaving the post natal ward short of midwives.

Complaints were well managed within Liverpool Women’s Hospital. Considerable improvements had been made to the way risks and quality were managed within the trust but there was still further development needed to the way in which the organisation investigated serious incidents and learned from incidents and complaints.

We had previously inspected this service on 7 and 8 July 2013. During this inspection we found there had been some improvements in how women and their babies were cared for and in how staff were supported. However, there were other areas where the trust failed to meet essential standards of quality and safety. Part of this inspection was undertaken outside of normal working hours. We started the inspection at 6am to see how women and their babies were cared for during the night shift.

We spoke with ten women and four relatives during our inspection who all spoke positively about their experiences at the hospital. Their comments included:

“It has been brilliant; they told you what was happening,"

“There are no words to describe how grateful we are,”

“They made my stay a happy one,”

“They explained everything to me.”

Staff at all levels were better supported to undertake their roles through training and appraisal, and staff morale throughout much of the maternity directorate had improved. However, maternity staffing levels were still sometimes inadequate, which meant that the trust was not always able to provide safe and effective intrapartum (care during childbirth) and post natal care to women and their babies.

There were systems in place to assess risk and quality within the trust, but the quality of these systems was not adequately managing risks to staff and patients. Improvements were also needed in the way in which the trust handled complaints.

Patients told us they felt fully involved in making decisions about their care and treatment throughout their stay.

Patients gave us good feedback about their experiences at the hospital. Their comments included;

“We can’t fault them, they have looked after us from start to finish”.

“I had a very nice midwife who took care of me”.

“It has been brilliant, we have had a good experience here”.

“I was close to giving up the breast feeding but they got me through it”.

“I would give the service ten out of ten”.

‘’Midwives have been amazing, I couldn’t have coped without them’’

We found patients were protected against the risks associated with medicines because arrangements were in place to manage medication safely.

Patients were cared for and treated by staff who had undergone appropriate pre employment checks, in line with NHS employment requirements, before they started working at the hospital.

Overall patients gave us good feedback about the support they had received from staff and staff told us they felt sufficiently trained to meet their roles and responsibilities.

A complaints procedure was in place which enabled patients, carers and visitors to complain if they were dissatisfied with the care or treatment they had received. Systems were in place to monitor all concerns and complaints and to ensure learning took place from these.

We spoke with 13 patients about the care they received and how their medicines were handled.

One patient said ‘’ I had been in pain at one point and the staff brought effective pain relief immediately’’. Another said I got my pain relief “as soon as I asked for it”.

A patient told us ‘’they missed my painkillers once but I rang my bell and they came right away”. Another said their pain was not fully controlled and expressed frustration that the medicines they were prescribed were not fully effective.

We spoke with seven patients about patient controlled analgesia (This is when patients can self inject a pain reliever using a special device). All said they were provided with detailed information about what it was and how to safely manage it.

One patient told us about their take home medicines and said they had been handled properly. Another told us nursing staff had explained what all her medicines were for and how to take them.

A patient told us “my medicine had recently been changed to an injection and staff clearly explained to me why this had been done’’.

We asked people using the service to tell us about how well staff explained their care, treatment and support choices to them. We asked questions such as whether people felt they had been given enough information and choice about their treatment, if pain relief had been discussed and if they had been given information about their recovery.

The feedback we received from people was very positive. People told us that they had been fully involved in decisions about their care and treatment throughout their stay and they felt confident to ask staff questions about their treatment. People’s comments included the following;

“Staff have spent a lot of time explaining things and have encouraged me and my husband to ask questions”.

“I have asked lots of questions and they have always been answered”.

“I had a birth plan that I was involved in”.

“I can’t fault how I have been treated. It has been exceptional, I feel staff communicated everything I needed to know”.

“I was given a lot of information about the procedure and what to expect following it”.

“They have been completely open and honest and they have listened to me".

“I’ve talked with staff about how the birth might be. I’ve been given information about birth and pain relief".

People overwhelmingly told us that they felt included and involved in decisions about their care. However, a small number of maternity patients said that they did not feel that they had the opportunity to discuss birthing options and pain relief prior to their admission as part of their antenatal appointments. They did however tell us that they had been given written information on birth and pain relief.

We spoke with a number of patients and their relatives about their experience of care, support and treatment across the wards we visited. We asked people a variety of questions including questions about their comfort, pain relief, privacy and dignity, and if they felt safe. We also asked people to tell us their overall view of the quality of the service they were receiving. Every person we spoke with made positive comments about the care and treatment they received and we did not receive any negative comments. People’s comments included the following;

“I would give them ten out of ten. Everything has been brilliant. I couldn’t have asked for more. Anything I wanted I could get, staff have checked on me constantly and never left me alone it’s been superb really”

“They discussed my plan of care with me”.

"It's been brilliant"

"Staff have supported me with my baby and helped me to feed her and settle her".

"I had a midwife with me all of the time. They were brilliant with me and my partner"

"I couldn't fault the care I've had".

"I've had pain relief when I've needed it and they have helped me when I've not felt so well".

We asked patients if they felt safe during their stay and they told us that they did. One person said “I definitely feel safe”. Another person told us “Yes, I feel very safe”.

People told us that they would feel confident about telling someone if they were worried about their own safety or the safety of another patient. One person commented, “I would tell somebody if I didn’t feel safe or if I thought another patient felt that way”.

We asked people who were using the service a range of questions about the staff. We asked people to tell us if staff responded to them in an appropriate and timely manner, whether or not they felt confident in the skills and knowledge of the staff team and whether staff were meeting their needs. Each of the people we spoke with gave us very positive feedback about staff. They told us that staff responded to them quickly when they were needed and that staff appeared well trained and competent. People’s comments included the following;

“I can’t fault the staff they have been absolutely fantastic”.

“All the nurses have been brilliant”.

“They have gone the extra mile”.

“One of the nurses sat with me and reassured me for much longer than I expected”.

Our rating of services stayed the same. We rated it them as good because:

• There were enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
• The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
• Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• Staff assessed patient risk well. Staff identified risks to patients and took appropriate measures to mitigate these risks.
• Medicines were prescribed, administered, recorded and stored well. Patients received the right medication at the right dose at the right time.
• There was an established Maternity Services Liaison Committee (MSLC), which provided an effective channel for users of maternity service to influence the local provision of maternity services.
• Community staff made prompt and timely referrals for women and babies that were identified as vulnerable and there was evidence that the trust worked closely with the enhanced midwifery team, safeguarding team and social services.
• Parents were involved in choices about their baby’s birth both at booking and throughout the antenatal period.

However:

• We found that some governance structures, processes and initiatives were recently developed and had yet to be fully embedded and audited in practice.
• Staff did not always have prompt access to up-to-date, accurate and comprehensive information on patients’ care and treatment.
• Managers across the hospital did not always promote a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
• Computer information systems needed to be enhanced, streamlined and developed further to reduce and mitigate risks.