Inspection of maternity service in Banbury finds 'babies could be put at risk of harm'

An inspection has found "poor governance and ineffective systems" at a maternity unit in Banbury, could put women and babies "at risk of harm".

Maternity services at Horton General Hospital have been rated as requires improvement, following an inspection by the Care Quality Commission (CQC) in October.

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.

It's the first time maternity services at Horton General Hospital have been rated as a standalone core service. Previously, maternity and gynaecology services were inspected and rated together.

The hospital said it was improving.

Milica Redfearn, Director of Midwifery at Oxford University Hospitals, 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."

Inspectors found:

• The service wasn’t always following the best practice guidance by ensuring a second midwife was available to support during later stages of labour and birth.

• Although staff had access to policies and procedures, some policies were hard to follow and hadn’t been updated to reflect changes in other policies.

• Medicines were prescribed correctly and stored securely, but they weren’t always kept at the right temperatures.

• Staff didn’t always follow the trust’s policy to clean the birthing pool and ensure it was decontaminated correctly after use. However, the trust was taking steps to address this.

Carolyn Jenkinson, said “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."

“It was also concerning that safety equipment wasn’t always checked regularly, which meant some out-of-date equipment and products might be used on people."“Staff weren’t always recognising and reporting incidents and near misses when they should have been."“We’ll be monitoring the trust closely, including through future inspections, to make sure women, people using the services and their babies are safe.”

Following the inspection, the ratings for Horton General Hospital have also changed. The overall rating for the hospital has been downgraded from good to requires improvement, as have the areas of safe and well-led.The overall rating for Oxford University Hospitals NHS Foundation Trust remains as requires improvement.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."“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."