Having spent a very long time looking through reports, I think I feel that the quality of them has improved somewhat in those published this year (these would be ones inspected a few months prior to that, but the reports take a while to compile and publish).
I do think there are still very real issues with some though, and there is a culture of hospitals trying to get one over on the CQC. I wonder just how robust the CQC will be on the subject. Especially once the spotlight moves off maternity.
My main beef is definitely with the 'Caring' Element of how they assess maternity.
There is a real lack of quality to it, even now and the quality of evidence is not really explicitly stated.
A lack or low level of complaints is used as a marker of there being no problem - rather than an exploration of the demographic of the population the hospital serves and what barriers they may face to making a complaint. A hospital in a deprived area which has a high number of women with learning difficulties and can't speak English is unlikely to have many complaints. (Report from May 2015).
Another example for you
Recent feedback from women indicated that their confidence in maternity services staff had improved. The results of the 2013 national maternity survey found that this Trust scored close to the national average on the question about the kindness and understanding of staff after a birth. We received mainly positive comments about care on the postnatal ward. However, one mother spoke to us about lack of support on the postnatal ward after a difficult birth, after which her baby was in special care.
Just to point out that this report was done in Jan 2015 and they are pulling out statistics for the Trust as a whole from 2013 relating to the kindness and understanding of staff after a birth and they also state that they received ‘mainly positive comments’ about care on the post natal ward.
This is based on interviews with nine patients to begin with and this was whilst there is an inspection in progress. So that one mother represented over 10% of cases (and still assuming that all of those nine patients were all postnatal patients rather than antenatal or gynaecology). This is also in the context that even with the unannounced visits they are so close after the announced ones, you would expect everyone to be on their best behaviour still just in case!
The report really down plays the feedback it gets as being 'unreliable' which I think is a worrying attitude.
Especially when you also consider the following:
NHS Friends and Family test (July 2014): the average score for urgent and emergency care was 18, which was worse than the national average of 53. The response rate was 17%, which was worse than the national average of 20.2%.
The average Friends and Family score for inpatients was 65, which was worse than the national average of 73. The response rate was 33%, which was worse than the national average of 38%.
The average Friends and Family score for maternity (antenatal) was 17, which was worse than the England average of 62. The average score for maternity (birth) was 62, which was worse than the England average of 77. The average score for maternity (postnatal) was 30, which was worse than the England average of 65.
Is tucked away in the report, not in the maternity section but in background information to the hospital (and not actually mentioned at all in the main body of the report for the maternity department).
The same report said
Women said that food was adequate and snacks were available outside meal times.
Women told us they fully understood the choices they made and had consented to, such as the options for screening or the reasons for elective caesarean section.
Women were involved in choices about their care, there were initiatives to encourage natural birth.
We observed nursing, midwifery and administrative staff interacting with women with kindness and understanding, even when they were under pressure. Staff demonstrated an awareness of the importance of maintaining women’s dignity and privacy.
Patients reported feeling involved in their care and said how well doctors and midwives explained the care and treatment at antenatal appointments and answered any questions they had.
Which I do think are phrased in a way that really could be potentially misleading as being high quality evidence.
In another report there was one reference I saw pointing to thank you cards of appreciation being used as markers for there being a caring culture at the hospital. Which I thought was pretty much someone writing something under the area for the sake of writing something because they couldn't actually find any other evidence and they had to put something.
Another pointed out helpfully under the headline that leaflets on how to complain were available. (So obviously since people didn't there wasn't a problem I assume is the logic here).
Most of what is written seems to be on the direct observations of what inspectors are seeing - without any discussion about how behaviour might change in the presence of inspectors or in the inspection period (they give 12 weeks notice, then do announced inspections and then do some unannounced ones shortly after). Of course this is going to potentially make somewhere look better than it might normally be.
Then there's the fact that I think women are generally very forgiving about the standard of care because the mentality of 'as long as the baby is ok' and 'the nhs can't afford anymore' is deeply ingrained and perhaps is more common in women than men. I think women will recommend an NHS hospital even if their care is below standard because they accept that and see it as a 'less worse option' if that makes sense.
I would like to see MN draw up and raise awareness of what is acceptable and what is not acceptable for this reason. Perhaps exploring whether women do actually recommend somewhere with this mentality. Or at least exploring the question of care, respect and dignity with specific questions rather than the very broad 'would you recommend this hospital's post natal services to a friend'.
I think that the worse examples of poor care are being picked on family and friends but I think lesser examples are being less picked up on and over looked. Plus the value of friends and family is not being given as much as it should be.
I have an example of a hospital which had just taken over services from another nearby. The CQC report did not pick up on problems and gave it a Good overall rating. Yet the month the change happened friends and family scores went through the floor (the number of incidents also went up). The friends and family figures looked to have been cherry picked as ones BEFORE the change happened. There would have been at least 3 months of data available with much lower scores at the time of the inspection. This is more worrying when you take into context why the inspection was being done in the first place - in part to see that the hospital was coping with transfer of services to the hospital.
The way that maternity units are rated is that you get five scores for each area. If you get 4 goods and one Requires Improvement then the overall score is Good. If you get 3 goods and two Requires Improvement then the overall score is Requires Improvement. The net result of this, that if you get a Good score based on really poor quality evidence the overall rating of the department looks a lot better. This means that putting a rating for the sake of putting something (on the basis of thank you cards for example) is potentially the difference between a Good or Requires Improvement.
Interestingly when James Titcombe's resigned from the National Maternity Review he said this:
“I feel the balance of the maternity review is weighted towards the professional voice.
“Those who have suffered avoidable harm or loss, the very people whose insights and experience we most need to learn from, are not in my view properly represented and are not being heard as clearly as they should.""
Which does tie in very much with what I think is happening in the CQC reports (Noting Mr Titcombe now works for the CQC!).
There does seem to be very much a Them and Us culture between patients and staff coming out in this. The CQC is supposed to serve the public yet, there is a real lack of focus on what the public are actually experiencing.
I have a list of 166 maternity units (this is not all the ones in England - I removed a few from my list because there was less than 10 months out of the last 20 of family and friends data to look at). Of these one scored 'inadequate', four scored 'requires improvement' and 10 scored 'outstanding'. All the rest got good. It seems like this was the far easiest category to get good in, and almost was the default position in the face of little evidence.
One of the ones good inadequate off the back of a group of women who actively requested to speak to the CQC and as a result took part in a focus group. The comments they made strongly echo those on this thread.
Yeah the Friends and Family scores didn't show anything that would suggest a problem. And the CQC's direct observations were all great.
WHY THE DIFFERENCE?
This is the ONLY report I've seen where a group of women actively did something like this. This made the difference between an overall rating of good and requires improvement. Something that I find quite telling and I do think there means there is lots of scope to really hammer home the point about what's going on in the experience of women and what's being put into reviews.
Like I say, I THINK they are actually on to this gap, but I don't think it would hurt to really ramp this up because I don't think there has been too much explicit on this nationally - only for particular hospitals that appear to be failing.
There was a drive to try and encourage hospitals to come up with innovative ideas for patient feed back in March too.
See link
www.england.nhs.uk/2016/03/maternity-patient-feedback/
It mentions this
The #MatExp Challenge Fund was created by NHS England at the request of Ben Gummer, Parliamentary Under-Secretary of State for Health. His Care Quality portfolio includes improvement initiatives such as the Friends and Family Test and other insight work involving patient feedback. He takes a particular interest in improving maternity services.
Do we know this guy? Another potential target for getting heard?
Is there a potential that MN could be a bridging link to this too on a longer term basis?
With regard to staffing levels, as I mentioned before there's definitely a problem with midwife ratio data in cqc reports though again I think recent ones have vastly improved.
What it doesn't say on any report what the staffing ratios on post natal wards are like. There is a focus on 1 to 1 care in labour and overall ratios but that's it. It does look like the numbers of midwives HAS improved, but what impact its had on post natal care is questionable.
The following two paragraphs are pretty typical of reports.
^The main risk was medical and midwifery staffing. Not every mother was able to have one-to-one care in labour at the current level of staffing. Midwives did not always take breaks and often reported working beyond the end of their shift. We saw that six incidents were recorded on the noticeboard where mothers had not had one-to-one care while in labour during January 2015. However, midwives thought this number was an
underestimate. They also pointed out that prioritising one-to-one care of women in labour at times of staff shortage created a risk that other women did not receive appropriate care. We saw a recent example of a woman not receiving one-to-one care pre-delivery, and the woman's care was compromised as a result.^
The lead midwife in each inpatient area assessed staffing levels for each shift. On identifying risk, and according to the escalation policy, the lead midwife contacted the on-call manager. However, we heard from staff and saw on incident reports that managers were sometimes unavailable. Unfilled shifts were the norm, so midwives were regularly relocated from less critical areas to support the labour ward. The escalation policy was used more often at night than during the day.
So the CQC are aware of the issue. The trouble is when they are doing reports they look at the department as a whole rather than looking at the separate areas of antenatal, birth and post natal much more generally. Maternity differs from other hospital departments because of this clear distinction between stages of care yet this balancing act is not really well reflected in CQC reporting. Instead CQC reports judge maternity as a whole (often also including gynaecology), the net result is that failings are being missed or not given sufficient weight because overall findings are so generalised. Splitting things more clearly and more obviously between each area is only really a matter of how they write up reports rather than extra workload to the CQC.
I do think that MN need to be a little careful about how they campaign here for this reason.
Hence why I campaigning ‘For hospitals to provide sufficient and appropriate staffing levels for all areas of maternity care including appropriate specialist midwives, support staff, senior midwives and consultant cover without compromise’ or something similar that takes into account what seems to be happening is in order to try and focus on one to one care, compromises are being made elsewhere. By campaigning for post natal care alone you actually run the risk of refocusing things and merely shifting it elsewhere!
Also I understand that the new model for funding maternity is hopefully going to tackle some of the issues that are effecting hospitals that take on the more complex cases. Until this kicks in, I think its difficult to push the more money case that hard at the moment, as the only response you’ll get is that its being dealt with. Unless you can highlight a particular area which is cause for concern and needs particular attention – which probably is best in relation to mental health staffing and training.
As for what the CQC put into reports about breastfeeding:
At best there is a paragraph, which usually says no more than the hospital is accredited somehow or is reaching its discharge target. Lots of reports haven't had anything at all.
And stuff about mental health is pretty limited too.
Sorry that's lengthy!
"
); care in the community from health visitors and community midwives; injury care for women post-birth, and longer-term care for pelvic floors; the six-week check and whether it really works for women and babies... but we're sure there are more. 
(After asking a few times, I was brought a jug of water a few hours later, but by then my DH was back and had brought supplies from the shop!). I also asked for paracetamol when the nurses came round offering pain killers - I said yes I would like some every time they came round, but it never appeared. So I ended up taking my own paracetamol from my handbag. I was also never given the help I asked for multiple times with getting DD's latch right (both in hospital and when I was at home).