Maternity Reports
Our services are monitored by independent organisations to make sure we are providing the best possible care for you.
On this page
Perinatal Reviews
We have independent perinatal reviews into maternal deaths and neonatal deaths which are expected to be finalised by Autumn 2025.
These independent reviews help us to identify learning opportunities and continuously improve the quality of our service and will be published here.
Care Quality Commission
Background of our CQC Journey
April 2022
In April 2022, Gloucestershire maternity services was rated inadequate by the Quality Care Commission (CQC) after previously being rated good..
The CQC is an independent (not part of the NHS) organisation that reviews health and adult social care in England to make sure services provide safe, effective, compassionate, high-quality care and they encourage care services to improve.
The CQC monitors, inspects and regulates services and publishes what they find. Where they find poor care, they can use their powers to take action.
You can read the report about our maternity service here.
The CQC looks at five areas of our service in order to give us a rating. They inspect whether our service is:
- Safe
- Effective
- Caring
- Responsive
- Well-led
The reason maternity services in Gloucestershire were rated inadequate was because the CQC felt we needed to improve our performance in two areas: safe and well-led. In the areas of effective, caring and responsive, we were rated good.
The areas of concern were in governance and staffing.
- Staff (particularly agency staff) knowledge and experience of Trust systems.
- Sharing of learning from incidents
- Learning from investigations and concerns raised was not always effective and therefore did not embed changes that would improve care for women and people who use maternity services.
- Processes were not effective enough to consistently identify and embed good practices.
- People’s experience of using the service was not always positive and some felt they were at risk of harm.
- A theme from complaints received by the trust related to staff knowledge and experience.
Because of these concerns, the CQC issued our maternity services with a section 29A Warning Notice
The CQC did note in this visit that responses to Friends and Family surveys showed over 85% of people who used the service had a positive experience.
After an inspection, the CQC will always produce a report. They can in addition issue ‘enforcement notices’ where it is felt the pace of progress is insufficient, or there is felt to be a more immediate issue.
April 2023
In April 2023, the CQC came to inspect our services again but despite the improvement work we had done over the last year, the evidence we provided of stronger reporting processes and shared learning, they felt further work was still needed and our rating remained inadequate.
The CQC issued an updated section 29A Warning Notice
March 2024
The CQC inspected our Maternity Services again on 26 March 2024. They provided initial feedback that there were no immediate safety concerns and that improvements had made in the culture within the department. They also requested a range of further information about service developments.
Despite the work we had already been doing to strengthen reporting process, and the way learning was shared, it was identified that further work was still needed in these areas.
As a result, the CQC notified us in May 2024 that a section 31 enforcement notice would be issued. As the service had been issued with a section 29a warning notice previously, this is the next step in the CQC process. A number of reporting conditions were put in place to ensure we focused our attention and increased the speed of change, including:
- Stronger systems to provide and up to date and overarching view of quality and safety across the maternity service;
- Systems and processes to identify and action timely identification and learning from incidents across all teams in the department.
These include immediate actions that the Trust is expected to take, and the service is required to report progress to the CQC on a monthly basis. There is additional system oversight and coordination in place so we can ensure that improvements that need to be made are embedded.
Stroud Maternity Hospital
As part of a separate inspection Stroud Maternity Hospital was rated "Requires Improvement" by the CQC and the report was published in March 2024 (inspection Dec 2023). The required improvement ratings were for the domains' safety and well-led. There were 6 Must-do actions and 4 should-dos. One of the recommendations was to "improve the model of care to ensure that it is fit for purpose." This is being overseen at our Maternity Delivery Group and within the services’ Clinical Governance framework.
The CQC rated Stroud Maternity Unit as requires improvement because:
- Compliance for safeguarding training was low, staff did not always ensure equipment was safe and ready for use and medicine management was poor.
- Staff did not always complete risk assessments or follow policy to ensure women and birthing people were suitable for care and birth, and documentation was not always contemporaneous.
- There was ineffective governance process and oversight, and leaders did not always manage risk and manage safety incidents well. Leaders did not always use reliable information to evaluate and run the service and there was limited engagement with the team and community to review and develop the model of care and services provided.
However, the CQC noted that:
- Staff had training in key skills and controlled infection risk well.
- The team at Stroud Maternity Unit worked well together for the benefit of women and birthing people and were passionate about the philosophy of the unit.