• CQC to take Assurance from External Accreditation bodies


    HLS Clinical Excellence Partnership have developed new Maternity Excellence Standards, and are currently taking part in the CQC and UKAS healthcare accreditation pilot.

    To be part of our journey, gain independent assurance of your clinical service and become involved with our national networking and learning events contact us now!

    Register Now

    They support maternity units to incorporate quality initiatives into everyday clinical practice. Achieving certification is a way of assuring women, their families, staff and organisational leadership that a high-quality service is in operation. It demonstrates that an effective quality management system is established, and there is a clear commitment to continual improvement.

    Giving Confidence to Deliver Quality Healthcare


    National Clinical Priorities

    • Maternity services in the UK are under increasing scrutiny, and increasing pressure.
    • Birth rates are rising,
    • staffing levels are challenging and
    • the CQC and the media are consistently present in the minds of maternity staff and organisational management.

    National initiatives are calling for the UK to improve on its ranking of 24th out of 49 for still birth rates in high income countries, NHS England have a target to halve the rates of still births, neonatal and maternal deaths; as well as intrapartum brain injuries by 2030 and NHS England has introduced a new Improvement and Assessment Framework for CCGs, stating maternity as one of the five areas of clinical priority.

    Maternity services across England are to become:

    • safer, more personalised, kinder, professional and more family friendly
    • where every woman has access to information to enable her to make decisions about her care; and
    • where she and her baby can access support that is centred on their individual needs and circumstance

    Staff are to be:

    • supported to deliver care which is women centred
    • working in high performing teams
    • in organisations, which are well led
    • in cultures, which promote innovation, continuous learning, and where they
    • break down organisational and professional boundaries

    (Better Births 2016)

    The role of the Care Quality Commission

    The Care Quality Commission has been working with Healthcare Quality Improvement Partnership (HQIP) to improve the quality of healthcare service accreditation. The Clinical Services Accreditation Alliance were a group of professional clinical bodies whose aims were to ensure that any accreditation or certification scheme in the UK had a patient focus. This will ultimately lead to improvements in the standards of care whilst having minimal administrative burden on the healthcare system.

    This is a major health accreditation initiative, and could be the start of an entirely new way of the health service being scrutinised. Maternity services have the option now to engage with other accreditation/certification schemes other than the CQC. Providing external assurance report to the visiting CQC inspectors, shows a commitment to quality and to continual improvement; it allows problems to be identified and solutions to be found before the CQC inspectors come on site. It give maternity services management and organisational leadership assurance that systems and processes are in place within maternity, the same way the NHSLA CNST Maternity Standards used to do.

    What does quality improvement mean to us?

    A quality maternity service is one which is safe, effective, woman-centred and efficient. This means having a framework in place which clearly illustrates a commitment to quality and continual improvement. It requires fostering a culture in which staff are content, open, honest and show integrity, and cultivating a workforce who are visibly committed to correcting issues which could lead to substandard care for women.

    Why use the Clinical Excellence Partnership Maternity Standards?

    Because we are new

    The Standards are currently in pilot stage and organisations who join the partnership will be able to drive the future direction of the standards. We have had the enviable position of being able to align our standards with current national guidance and engage with key stakeholders – we are completely up to date.

    Our Standards have been written to conform to national and international guidance on standard development. We meet the requirements of:

    • International best practice clinical guidelines
    • National priorities such as those determined by NHS England
    • CQC Inspection Framework
    • ISQUA International Healthcare Accreditation Scheme
    • UKAS, HQIP and the CSAA requirements for Clinical Service Accreditation
    • PAS 1616:2016 Healthcare – Provision of clinical services – BSI Specification

    References are provided for maternity service to look in more depth about the Standard requirements and their origins.

    Our assessment process is designed to be part of ‘business as usual’

    • We use clinicians who know and understand the services provided
    • Our Standards are clinically specific to maternity services; and include maternity outcomes and the management of high risk cases.
    • Our standards are clinical, outcome focussed, measurable and evolving
    • We will assess the quality of care provided, in real time, with women who are receiving care
    • The process involved talking to women and their families about the care that they have received; we will identify if the women felt central to the decision-making processes, whether her wishes were adhered to, and whether she was treated with compassion, dignity and respect.
    • Our assessment process is assimilated into your daily routines – meaning minimal preparation, no disruption.
    • We are supportive, non-punitive and we will work together to formulate improvement plans
    • Self-assessment tools mean you can track progress and determine levels of compliance within the service
    • Joining HLS CEP means joining a Quality Improvement Programme, an invitation to a facilitated learning and sharing environment
    • As ex CNST assessors, we know the positives and negatives of assessment and can use this experience to enhance the certification process and reduce the burden on services

    Our objectives are purely to improve quality within maternity services

    The Clinical Excellence Partnership was founded by professionals who are experts in healthcare, standard writing and assessment. It was set up to:

    • Help facilitate the improvement of maternity services by increasing the number of services certified
    • Ensure a quality service for staff, women and their families
    • To reward maternity services for their commitment to safety and quality improvement
    • Offer third party assurance without additional work or disruption to everyday clinical care
    • Provide an assessment methodology that includes a process to determine that the woman and her family were central to decision making
    • Build strong relationships with stakeholders, including commissioning bodies, regulators and professional groups
    • Provide a high quality, cost effective scheme for maternity service.

    Accreditation Process

    Scope of the Maternity Clinical Standards

    The scope of the Standards is to certify the antenatal, labour and birth process of women within the community and acute healthcare setting. This includes women:

    • Who deliver in consultant led unit
    • Who deliver in midwifery led care
    • Who deliver at home, or
    • Who require transfer from home into acute services,
    • Who require transfer from midwifery led care to a consultant led unit
    • Who required inter hospital transfer

    Reviewing and maintaining the Standards

    • The CEP Standards will be launched in draft in April 2017, and there will be a 12-month programme of pilots, consultation and collaboration to refine them for official launch in April 2018.
    • There will then be a three-year revision period, with changes being made and version 2 issued in April 2021.
    • Small issues, which do not significantly change the content and meaning of the Standards may be made annually based on feedback received from surveyors and maternity services
    • Maternity services and other stakeholders will be involved in the ongoing consultation process. The mechanisms for submitting queries, comments and suggestions will be via the use of standard review questionnaires (to comment on the content of the standards) and post survey questionnaires (to comment on the satisfaction of the assessment process and methodology).

    Self-assessment and health record review

    • A self-assessment package is available upon request. The package includes a health record review tool, sample methodology and sample job description for a CEP lead within the maternity service


    • The pre-assessment is optional, and shall provide an indication to the maternity service whether relevant aspects of the standard have been addressed. Pre-assessment is a service offered prior to commencement of the certification process. The pre-assessment consists of a document review and site visit (can be done in parallel).

    Initial and Periodic Assessments and the 3-year cycle

    The assessment will include a series of activities that will include:

    • Review of previous assessment results and implementation of associated corrective action plans;
    • Interviews with maternity service leadership and key medical and midwifery staff,
    • Interviews with patients;
    • Environmental tour;
    • Interviews with individuals who oversee core processes (e.g. patient safety, infection control, etc.);
    • Human Resources interview to verify compliance with staff requirements;
    • Additional document review if deemed necessary by assessment findings.

    Standard Development Process, Development and Review

    These standards are currently in a pilot year, the Clinical Excellence Partnership will consult, learn and improve in order to formulate the final Certification Programme for Maternity Services in 2018.

    We are currently at pilot stage – if you wish to support us in this project, and help us formulate a robust, and clinically relevant set of Standards, then please get in touch.

    Please register your interest in becoming a pilot site, or provide comment on the Standards:

    Register Now

    Workshops and Learning Events

    A number of workshops and learning events are being held throughout the year, from small scale in house, tailored training events, requested by maternity services; to larger learning and sharing events where we aim to bring together people with the aim of facilitating improvements in clinical care. Please register your interest in receiving information on such events below:

    Register Now

CQC to take Assurance from External Accreditation bodies
‘An up to date, structured and comprehensive set of Standards which services can utilise before a CQC inspection, and provide the report as evidence’

Harriet has spent a number of years assessing maternity services against the NHSLA Clinical Negligence Scheme for Trusts Maternity Standards in the UK. She has also been involved in designing and implementing clinical services accreditations, including maternity excellence standards, throughout Europe.

'I believe that an external pair of eyes, can help services focus on issues which require improvement. If this is done in a supportive way, which does not disrupt services, combined with an assessment process which requires minimal preparation, then this is an invaluable opportunity. We can use a structured and comprehensive set of Standards which services can utilise before a CQC inspection, and then provide the report as evidence. The Clinical Excellence Partnership aims to assemble a Quality Improvement Partnership, one which encourages the sharing of learning across regional boundaries and facilitates networking'.


Sue Harris has worked in healthcare for over 30 years, has an MSc in Health Services Management and she is an expert in maternity care. Her mission is to make hospitals a better, safer place for patients and staff. She believes that external certification is a powerful way to improve consistency and quality of care through robust scrutiny. Sue started her career as a nurse and midwife and then went on to manage maternity units in Essex and the East Midlands. She then used her varied experience in her role as CNST assessor for the NHS Litigation Authority, prior to the withdraw of the standards in 2014. Sue was a member of the core team that revised and updated the CNST maternity standards.

Since then she has worked with charities including Macmillan Cancer Support, Bliss, the neonatal charity, and Rethink Mental Illness. She has been a member of international hospital audit teams in the UK, Europe and China and has also written and delivered risk management training in both the UK and the United States. Sue also has a keen interest in leadership development and has been a member of the Scout Association as either a leader or volunteer manager since 1985.