Improving Quality of Healthcare Services at Morecambe Bay NHS Foundation Trust

This case study examines the failures in healthcare services at Morecambe Bay NHS Foundation Trust and provides recommendations for improvement. It highlights the lack of training facilities, ineffective care practices, and the need for better monitoring and supervision. The implementation plan includes training programs for staff and continuous monitoring of patients.

MORECOMBE BAY

Table of Contents
INTRODUCTION...........................................................................................................................3
TASK 1............................................................................................................................................3
Use process mapping tool, identify and analyse aspect of service failure in above case study...3
Organization standard and expectation-:.....................................................................................5
TASK 2............................................................................................................................................6
Recommendation for improving the service delivery..................................................................6
TASK 3............................................................................................................................................7
Devise implementation plan on above two mentioned recommendation....................................7
CONCLUSION................................................................................................................................9
REFERENCES..............................................................................................................................10

INTRODUCTION
Quality in health care is one of crucial management system that aids to determine result
and quality of the services to patinets (Monicah, Maria and Yan, 2020). Therefore, quality
healthcare termed out as care that is safe, effective, patients centered, efficient and equitable. In
this case study, inquiry has been undertaken on deaths of 11 babies and mother at Furness
hospitals cumbriya that has investigated that midwives were so cavalier they were nicknamed the
musketeers. There was an issue that led to the unnecessary death of one mother and 11 babies in
the maternity unit. For this, Morecame investigation was set up and there serious issues has been
identified in which frontline staff were responsible where is unsafe care practices undertaken.
Henceforth, study will use process mapping as tool to identify and analyse an aspect of service
failure as per above case study. Also, assignmnet will cover suggestive measures that assist to
imporve the service delivery. Lastly, study will draw implementation that can be used to execute
two of the above mentioned recommendation.
TASK 1
Use process-mapping tool, identify and analyse aspect of service failure in above case study.
Inquiry findings-: Furness hospitals Cumbria was failed to provide safe, effective and proper
care to patients. One of the most significant things that has been analysed from the case study is
lack of training facilities to staff of the hospital (Mays and Pope, 2020). To identify the causes of
failure Morecambe investigation was set up by the health secretary. Thus, front-line staff were
responsible for undertaking inappropriate and unsafe care practices. Due to ineffective care of
midwives the inquiry has been conducted on the deaths of 11 babies and mother at Furness
hospitals in Cumbria. In this, it has been found out that things were happening due to seriously
dysfunctional with poor levels of clinical competence, extremely poor working relationship and
determination among midwives to pursue normal children (Taylor, Clay-Williams and
Braithwaite, 2020). Due to this, there are number of the outcome of the services that has
impacted the health of patient in many ways. Therefore, this has been considered that due to lack
of seriousness and ineffective services of midwives to patients created serious incidents
happened to patients. This all working has reported as a results of unnecessarily harm that caused
to the patients. Failure of process mapping such as-:

Figure 1: Failure of process map
Process mapping-: Process mapping termed out as visually demonstrates the steps and decision
in a particular process (Miranda, Snowden and Legha, 2020). It is flowchart that defines flow of
materials and information that associated with process. This can be stated that process mapping
is termed out as graphical representation that is illustrative with description that how things get
done. It is helpful to participants to visualise the process details that closely and guides the
decision-making. However, the process map is one of the proficient tool that assist to reflect the
inputs, actions and output of process map in clear and this leads to step by step map of the
process (Northridge, Kumar and Kaur, 2020). Thus, one of the major objects of process mapping
is to support medical staff and authorities to understand the process effectively and efficiently.
In the present case study, the overall process map failed as the front line officer was not
taking their responsibilities effectively and firstly they do not render effective guidelines to
patients. Inappropriate and unsafe care has created the potentially fatal incidents. As a result, the
11 babies and death of a mother has been reported. Thus, major issues has been identified that
the medical authorities was not giving proper training facilities to the patients and this was
causing harm to the patients. In order to undertake the ideal process map, the front line officer
following things can be undertaken such as-:

Figure 2: Process flow map
In the above process map, the front-line staff of the hospital needs to follow the above
mentioned procedure so that better things can be undertaken. Hence, at the Furness hospitals
cumbriya the following issues has been found out such as are:
 At time when patients are come to hospital the front-line officer were not given the
responsible and effective guidelines to the patinets due to this they are getting the
ineffective tratment.
 The midvives of the health organisation were not properly trained and they renderd the
ineffective treatment to the patinets that cause harm on the health of patients (Sloane,
Silbersack and Zimmerman, 2020).
 Henceforth, it has been found out that maternity services were beset by culture of denial,
collusion and incompetence. In critical cases, midvives pursue normal childbirth at any
cost and this leads to cause death to babies and women.
Henceforth, this can be stated that the lack of improper and ineffective care to patients
providing proper care facilities. Thus, front-line officer was responsible for providing
inappropriate and unsafe care that this potentially creates the fatal incidents. In the unit, this also
has been found out that poor levels of the clinical competence, poor working relationship and

determination among midwives leads to pursue normal childbirth at any cost (Conijn, van der
Ark and Spinhoven, 2020). Therefore, ineffective services of the medical staff were responsible
for inappropriate and unsafe care as they lack with training facilities.
Organization standard and expectation-:
NHS foundation trust has set their own standards and this is crucial for all hospitals under
the Morecambe NHS foundation trust to follow the all specified standards. In order to undertake
the proper care facilities, the plan needs to be implemented with help of using National quality
standards (Peterson, 2020). Herein, all the services standards are specified that needs to be
accomplished.
The patients need to be observed at least once among 24 hours so that health outcomes of
patients must be monitored in regular intervals.
 All the Hospital staff member needs to be trained and hire staff should be hired so that
they can able to diagnose the patients issues in much more effective manner (Ramori and
Antony, 2019).
 The midwives need to treat the pregnant women with more responsible care and they
must provide the proper guidelines and advise that whether they need C section birth or
normal child birth.
 In this, it can be stated that waiting time for the patients should not be the long and they
must be responded quickly (Huang, Liu and Xu, 2019).
 Hence, the another ward for babies needs to be created so that they can he held them for a
day to give proper care after birth.
 All the patients are diagnosed and treated within effective and efficient manner.
However, from the above all specified health standards for the patients there are few rules that
the NHS trust failed to accomplish and due to which patients were not receiving the quality care
(Pika, Wynn and Reijers, 2019). Standards that Morecambe bay NHS foundation trust failed are
determined in the following manner as are-:
 The front-line officer of the entity was not properly skilled and trained. Thus, they failed
to provide the proper guidelines to patients and due to they do not get observed
effectively (Angoff and Baggett, 2019).

 There were not skilled and adequate number of midwives who can render proper care to
the pregnant women on time and needs to render the proper care to them.
 The flow of the patients within the hospital is not proper as the patients has to wait for the
long at all the phases of their treatment.
Current mission and vision-:
 Vision- To take the steps to develop partnership between the patients and practitioners in
terms to render the quality health services to patients.
 Mission- The main mission is that 'the heath entity must work together and receive best
evidence based care with the available resources. They need to ensure that patients needs
to be heard throughout the journey of their treatment.
 Objective- The main objective is to deliver the high quality, efficient services with
proficient care facilities to patients. Thus, midwives of the entity must be skilled so that
they can able to provide reasonable care to pregnant women and effective child birth can
be taken. Also, they assume to prevent and manage long terms conditions that assist to
improve health care quality and bring out reduction in health inequality with facilitating
training facilities to patients.
TASK 2
Recommendation for improving the service delivery
This is significant to offer effective health care facilities quality in all the organisation.
There are number of the levels in the Morecambe Bay NHS foundation trust with quality care to
patients. It is significant to improved so that all the failures and flaws needed to be improved to
render effective care to patients (Taylor, Clay-Williams and Braithwaite, 2020). Quality
improvement in the healthcare is crucial as this enhance the readability of the health condition of
patients. Hence, to render the effective quality facilities can be termed out as systematic, data
guided activities that are mainly designed to bring out immediate suggestive measures in
healthcare delivery. To improving the quality of care is one of the priority that leads to
accomplishing the high degree of patient’s satisfaction. Health care organisations are responsible
to improves customer satisfaction that leads to improve outcome of patients. Quality of care is
one of the key components of the right to health that offers the route to equity and dignity for
women and children. Henceforth, recommendation has been outlined in following context as are-

 In health care enterprise, the patients are needed to be diagnosed in proper manner.
Patients needs to be admitted as per the condition and seriousness of the disease so that
the proper and adequate facilities must be rendered to patients (Bano, 2019).
 The health care enterprises need to render the effective training facilities to the medical
staff such as front-line officers, midwives and medical authorities so that patients can be
treated and diagnosed well.
 Medical authorities should teach midwives to conduct the better health care facilities with
all health care guidelines (Mays and Pope, 2020). Thus, they must have advised the
pregnant women to whether opt for C section or normal child birth by diagnosing their
condition. This process can lead to reduce the number of death of new born babies and
their mothers.
 Front line officer in the health care organisation must be responsible authority so that
they render effective and proper assistance to patients. Better training facilities to Front
line officer needs to be rendered to cope up with the inappropriate and unsafe care
 By doing continual monitoring and supervising of the patients the better quality care
practices needs to be given (Cooper and Skeen, 2020). Thus, all patients are needed to
regularly monitored within regular intervals of time. This leads to enhance the trust of the
patients about the medical services.
 Training programmes and seminars should be facilitating by the medical authorities.
Henceforth, effective training needs to be given to render quality care to the patients. This
kind of training can help to the midwives to understand the significance of effective
health care facilities. However, this training programme can assist to patients to learn out
the different measures that aids to attend the patients with quality care practices. With
help of interactive training programme and collection of trusted resources assist to
designed to help and improve health care quality.
Henceforth, this can be concluded that use of recommendation process map can be
helpful so that patients are continually monitored and quality care practices plays the huge role in
rendering better care to the patients.

Evaluate the failing against the organisation's standards on chosen national standard such as
CQC
This is termed out as the regulator that assist to monitors and inspects all organisations
providing care also safeguard standards are being met. All NHS and social care providers needs
to be registered with CQC and they must confirm to a set of standards. These are the standards
that can be found on the CQC website.
Failing process map meet the CQC
In case if the process map tends to get fail to meet quality and safety standards have been
given and the registered person fails to comply with the terms, a criminal conviction result in a
fine of up to £50,000 being handed down.
TASK 3
Devise implementation plan on above two mentioned recommendation
The suggestive measures given above can assist to improving the quality care to the
patients. This can be helpful in bringing the quality services in the hospitals. In order to
undertake improvement effectively, the few things are needed to be considered on priority basis
such as-:
1. Front-line officer of the entity must be given effective training to handle all the things in
effective and efficient manner.
2. Monitoring of the patients needs to be done in continual manner so that health outcomes
of patients regularly checked. It can leads to build better and efficient health care
services.
Implementation plan-:
Quality dimension Indicator Change idea
Training facilities Front-line officer and
midwives of medical
authorities must be trained
effectively so that patients can
have better health outcomes
(Monicah, Maria and Yan,
2020).
The health authorities must
provide 6 months of internship
to medical staff and then they
must render to probation
period of three months. After
probation period, only
effective employees need to be

hired. This can helps to
enhance professional
competency of entity.
Patients monitoring and
supervision
In this, patients are needed to
be monitored within each 24
hours. Thus, mid wives advise
pregnant women to take
normal childbirth no matter in
what conditions they are
suffering. This is serious issue
that affects the health of the
child and mother. Also, this is
one of the major causes that
lead to enhance death
outcomes of child and mother.
In this, separate monitoring
and supervision ward must be
facilitating for the patients
who are in critical condition.
Each patient must be kept in
separate room so that risk of
spreading infection to patients
can be reduced. Also, skilled
midwives needs to be hired so
that they can treat pregnant
women with reasonable care. It
will be helpful to reduce the
death outcome of babies and
child.
Henceforth, all stakeholders at the healthcare organisation inclusive of doctors, nurses
and patients etc. Midwives and front-line officers needs to trained properly. Monitoring and
supervision of patients must be undertaken effectively. It can be helpful to NHS to deliver the
quality improvement services within enterprise.
CONCLUSION
Hereby, it can be concluded that quality healthcare termed out as safe, effective, patinets
centered and equitable facilities to patients. Henceforth, health care services must be provided to
individuals and patients population to imporve desired outcomes of health. The present report is
based on topic inquiry has been undertaken on deaths of 11 babies and mother at Furness
hospitals cumbriya that has investigated that midwives were so cavalier they were nicknamed the
musketeers. There was an issue that led to the unnecessary death of one mother and 11 babies in
the maternity unit. Henceforth, study has outlined the process mapping as tool to identify and
analyse an aspect of service failure as per above case study. Also, assignmnet has covered the

suggestive measures that assist to imporve the service delivery. Lastly, report has outlined the
implementation of plan that used to execute two of the above mentioned recommendation.

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