Executive summary

NMC report on the extraordinary review of pre-registration nursing (adult) education and the maternity services at Basildon and Thurrock NHS University Hospitals Foundation Trust

This extraordinary review was carried out in response to public and system regulator concerns about poor standards of care at Basildon and Thurrock University Hospitals NHS Foundation Trust (BTUHNFT).

This is the first time a joint review has been conducted between the midwifery department of the Nursing and Midwifery Council (NMC) and the NMC quality assurance reviewers. Both teams considered the suitability of the learning environment for pre registration student nurses and midwives. The midwifery review team also considered whether women in the maternity unit were receiving safe care from midwives and whether the supervision of midwives was meeting the required NMC standards within the trust.

Overview and key recommendations

For the board of directors of BTUHNFT

For the maternity unit

Statutory supervision of midwives

For the approved education institutes (AEI) in partnership with BTUHNFT 

Overview and key recommendations

The NMC has reviewed the performance of BTUHNFT and its education providers Anglia Ruskin University and University of Essex against the NMC quality assurance framework and key standards set within the Midwives Rules and standards (2004) and the Standards to support learning and assessment in practice (2008). This element of the NMC review of the trust has focussed on the supervision of midwives and the safeguarding of the health and well being of women, babies and their families using maternity services at BTUHNFT.

The review team noted a number of examples of good practice regarding the delivery of maternity and nursing services, statutory supervision of midwives and provision of education for nursing and midwifery students. Whilst there was evidence that improvements have been made following the concerns raised by the Care Quality Commission (CQC) there are areas that require continued review in order to ensure the safety of the public. The main findings and recommendations of the review are as follows:

For the board of directors of BTUHNFT

  1. To provide evidence of the evaluation of the governance frameworks and continued improvements in the areas identified by the CQC.
  2. It is considered good practice and therefore recommended that the Director of Nursing (DoN) and Head of Midwifery (HoM) meet formally once a month to ensure patients, women and their families receive a quality service and a high standard of midwifery and nursing care. Furthermore it is essential that the DN escalates issues as appropriate to the Chief Executive (CEO).
  3. There is a perceived lack of confidence in the ability of the CEO and DoN to foster a culture of strong leadership and team working amongst the nursing and midwifery staff.  The CEO is responsible for fostering a culture where excellence in nursing and midwifery can flourish and support the DoN in achieving this objective. It is critically important that the DoN and HoM are supported to be champions of excellence in nursing and midwifery care and to ensure that students are afforded high quality educational opportunities.
  4. The emergency care pathway including the accident and emergency (A&E) department has been found to provide a variable environment and standard of care particularly when the throughput of patients is high. Given this variance, these areas should be monitored closely. Senior members of staff should be dedicated to overseeing these areas to ensure standards of care are not compromised during periods of peak activity and that a suitable learning environment for students is maintained at all times.
  5. To ensure that the trust risk framework recognises and reflects appropriately the high risk issues in maternity and obstetrics regardless of likelihood of recurrence. Lessons should be learnt and systems changed, where necessary, from all incidents with adverse morbidity and mortality outcomes, to improve quality and safety for women and their families.
  6. To support a robust maternity services action plan to address the midwifery staffing shortfall, and the other challenges the maternity services face. To regularly monitor its implementation in conjunction with the LSA to ensure that there is effective progress against it. 
  7. To facilitate increased engagement and regular communication between the maternity staff and all members of the board of directors of the trust in order to support the maternity unit with any necessary actions to further improve the service.
  8. To ensure senior doctors and midwives are supported to improve collaborative working that can provide demonstrable improvements to the care women receive.
  9. To establish whether there is a similar lack of collaborative and mutually respectful working between nursing and medical staff and take steps to support demonstrable improvements with these staff groups too.
  10. That the board identify a non executive director as a key supporter and challenger to monitor the action plans and who works with the DN, HoM and the Local Supervising Authority Midwifery Officer (LSAMO) to ensure that patients, women and their families receive high quality care at all times.

For the maternity unit

  1. Currently only 50 percent of women receive one-to-one care in labour and this compromises the safety of the service. The team should develop and implement a midwifery recruitment action plan as a matter of priority. A dedicated lead for this important work should be identified and a recruitment and retention midwife post could support this.
  2. The maternity clinical environment should be reviewed comprehensively and improvements identified in terms of:
    1. Adequate and safe space. The unit was built over 30 years ago when the birth rate and the clinical complexity was significantly different to what is today. The rooms in the midwife led birth unit (MLU) should be risk assessed for staff and patient safety.
    2. Adequate level of facilities for women and babies for example number of bathrooms.
    3. Improving the welcoming and inviting environment for women and families by removal of potentially alarmist equipment safety notices in public areas.
  3. Ensure that the teamwork and communication challenges identified between obstetricians, neonatologists and midwives working in the two birth units are addressed so that safety and clinical care is not adversely affected.
  4. Ensure that there is a robust structure in midwifery and strengthen the senior clinical leadership element where gaps are identified. Ensure that this leadership momentum is not compromised with the acting HoM leaving and the substantive HoM returning from her secondment in 2010.
  5. The LSAMO to support the supervisor of midwives (SoMs) and HoM in implementing service improvements to ensure that women and their families receive high quality care.

Statutory supervision of midwives

  1. The LSAMO to ensure that the SoMs make the decision for supervisory investigations individually as well as collectively, when the need arises. This should not be decided by someone acting in a trust risk management capacity. The SoMs need to ensure they remain impartial as they may have a different conclusion, regarding the need for action, to the trust risk manager. This will be supported by the training they have received regarding undertaking supervisory investigations and using the appropriate LSA guidance and templates.
  2. The LSAMO to ensure that the supervisory self assessment data for the annual audit is verified with the staff and women in the maternity unit.

For the approved education institutes (AEI) in partnership with BTUHNFT

  1. The AEI needs to put in place a robust reporting system so they can be assured that concerns regarding the standard of nursing or midwifery care is reported to them in a timely manner. Students can be then be supported or removed from the clinical environment until such time as the situation improves.
  2. To provide evidence that education audits map effectively not only the mentor register but also the staffing numbers to ensure there are sufficient staff to support students. If areas are found to be short staffed students should be removed until such time as the clinical area has sufficient staff to support and mentor them.
  3. Student midwives should be removed from the gynaecology ward until such time as there are sufficient staff to provide mentorship and the environment has suitable learning opportunities to support their midwifery education programme. This situation should improve when the new ward opens.
  4. The AEI to seek alternative placements for student midwives to enable them to meet the requirements until such time as the case mix problems on the gynaecology ward are resolved.
  5. Student nurse placements in the emergency assessment areas, including A&E, should be reviewed to ensure that they receive appropriate education, training and mentoring at all times.
Created date :
09/04/2010
Modified date :
09/04/2010