Royal Sussex County Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked if women were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked women’s liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question inadequate. At this assessment, the rating changed to requires improvement. Although we saw improvements some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. We assessed 8 quality statements.

The service was in breach of legal regulation(s) in relation to people’s safe care and treatment. The breach relates to appropriate management of risks including induction of labour, caesarean section delays, medicines management, safeguarding training and the premises at Sussex House. Sussex House is one of the hospital buildings where the maternity outpatients and the ultrasound service is housed.

Staff did not always understand and manage risks well. Safeguarding training figures were not in line with trust targets. The facilities and equipment did not always meet the needs of women, some environments were not well-maintained, and risks were not always mitigated. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

However, the service made sure there were enough qualified, skilled and experienced staff. People were protected and kept safe; the service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. Managers made sure staff received training and regular appraisals to maintain high-quality care.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff raised concerns and reported incidents and near misses in line with trust policy. Staff could access the incident reporting system, knew what incidents to report and told us how they reported them. Leaders provided feedback on learning from incidents via email, meetings and newsletters. Leaders would also give feedback directly to staff about incidents they raised depending on the severity.

Managers shared themes and trends from learning at handovers via newsletters. We saw evidence of changes having been made following learning from reported incidents. For example, staff identified a delay in placental histology being processed. The department worked with a local trust and adapted a sticker system to be placed in notes to identify high priority cases.

Staff discussed patient safety events monthly, including progress on reports and learning (both immediate and longer term). They noted action points and translated them into the rolling meeting action plan. The trust reported that maternity was the highest reporting clinical service of low and no harm incidents. The department felt this demonstrated a healthy reporting culture and provided opportunities to address concerns raised before harm was caused.

We reviewed several incident reports and saw that learning was discussed, and any associated actions highlighted. We observed an incident review meeting which was attended by the multidisciplinary team, including doctors and midwives and encouraged open conversation and learning.

We requested the departments policy in managing patient safety incidents however, local incident management procedures were not currently formally documented into a procedure/protocol. Governance leads were working towards a trust wide policy and approach. In the interim, staff used an incident trigger list to identify which cases would determine the method of investigation and the appropriate review tool. For example, multi-disciplinary review. Concerns had been raised about medical attendance at these meetings. As a result, consultants were now being given protected time to participate.

Governance leads were adjusting the template of the quarterly safety incident report to include near misses as well as no and low harm. This aimed to allow senior leaders to detect emerging trends and themes. Compliance with duty of candour was monitored through the maternity dashboard and showed that 100% compliance was maintained on a monthly basis

The department reviewed all fetal and neonatal deaths using the national Perinatal Mortality Review Tool (PMRT).

The evidence showed some shortfalls. The service worked with families and healthcare partners to establish and maintain safe systems of care, however, safety was not always managed or monitored in line with guidance. Staff made sure there was continuity of care, including when people moved between different services.

The service had developed a triage telephone line and clinic which women who were more than 16 weeks pregnant could contact at any time if they had concerns. This number was a single point of contact trust wide. Staff told us this was an improvement on the previous system. Women attended triage 1,605 times from October to December 2024. The most common reason for attendance was reduced fetal movements followed by suspected labour and feeling unwell.

The service now used a nationally recognised triage system to improve the safety of mothers, babies, and the management of the department. It consisted of a prompt and brief assessment (triage) of women when they presented with unexpected problems or concerns, and then a standardised way to triage the urgency in which they were seen.

The triage department had enough midwifery staff to safely manage the triage service. During the day, an experienced midwife manned the triage telephone, and a further midwife was available during peak times. An experienced midwife manned the triage telephone overnight. However, there were often delays in receiving non-urgent medical reviews as there was not a dedicated doctor allocated to oversee the triage service. Medical staff covered all ward areas, and the emergency department and were called to attend triage as needed. We witnessed delays to women being discharged or moved onto the wards because of medical reviews.

The CQC coordinates a national survey annually to look at the experiences of pregnant women and new mothers who used NHS maternity services. This survey looked at the experiences of pregnant women and new mothers who used NHS maternity services in 2024. It is CQC coordinated with other stakeholders but it is reported by us at CQC. We reviewed the latest findings of the Maternity Services Survey 2024. We saw that when women were asked about the last time they were triaged, did they feel that their concerns were taken seriously by the midwife or doctor you spoke to, the service scored 8.8, which was above the national average of 8.4 when compared to all other trusts in England.

We reviewed records that highlighted that the priority algorithm was not always followed. For example, a low-risk woman attended with reduced fetal movements (RFM) which had continued from the previous day was triaged within 15 minutes as a green priority rather than amber. The woman also had additional risk factors and there was also no obstetric review of the woman documented in the electronic records. The trust did not audit digital notes so there was a lack of oversight and learning in relation to the consistency of notes.

Staff attended two cross-site daily status (sitrep) meetings each morning where they discussed the current and emerging situation at both the RSCH and Princess Royal Hospital (east side of the trust) and St Richards and Worthing Hospitals (west side). The head or director of midwifery chaired the first meeting to a set agenda which included staffing, bed capacity and learning from recent incidents.

The second meeting covered all four hospital sites to include St Richards and Worthing hospitals. and used information from the first meeting to identify any areas of concern and address immediate concerns across the whole trust.

Staff of all grades attended regular safety huddles during their shift. This was an opportunity to share safety information. At the change of shift the medical and midwifery teams had handover meetings to discuss all women within the maternity unit. During the inspection we attended handover meetings and safety huddles. We found them well attended and used to fully discuss the patients and any emerging concerns.

Staff had access to guidelines via the trusts intranet and could demonstrate how to access them.

The medical team had a daily board round where they discussed the care and treatment of women in their care. We attended a board round during the assessment. The focus of these meetings was on the safety of women and babies and the utilisation of the main theatre. Staff also identified potential delays and postponements to women who were undergoing induction of labour or elective caesarean.

Women were included in discussions around transitional care. Women had access to virtual tours and hospital visits to ensure they were familiar with the environment before arrival. Community teams also supported women to ensure they felt comfortable before arriving in the hospital setting.

The service provided transitional care for babies who needed additional care. Staff completed newborn risk assessments using recognised tools such as the Newborn Early Warning Trigger & Track (NEWTT) tool to record observations and feeding.

Staff provided transitional care in a specific bay in the postnatal ward. Staff received support from the nearby special care baby unit (SCBU) as needed. Transitional care is an area within a maternity ward where newborns who need a little extra care beyond routine monitoring are cared for alongside their mothers, allowing for a smooth transition from delivery to going home. There was a close relationship between the staff working in the SCBU and maternity unit. All babies who needed special care or transitional care were discussed at an Avoiding Term Admissions into Neonatal Units (ATAIN) meeting. An ATAIN meeting focuses on reducing unnecessary admissions of full-term babies to neonatal units by identifying and addressing potential issues. This may include for example, breathing problems, low blood sugar, and jaundice, thereby promoting better mother-baby bonding by keeping them together as much as possible.

Women who were less than 16 weeks pregnant and had concerns about their pregnancy could access care in the early pregnancy unit (EPU) which was situated on the 11th floor alongside gynaecology wards. The EPU was open between 9am and 5pm Monday to Friday.

Safeguarding training figures for staff were not in line with trust targets. However, the service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately

The trust set a target of 90% for all mandatory staff training. Records showed 86% of midwives had received level 3 safeguarding training in children and young people. Midwives and nurses had achieved 80% compliance in level 2 safeguarding training for adults.

Current figures showed only one member of midwifery staff was trained to level 3 in adult safeguarding. National guidance suggests that midwives needed certain competencies in relation to adult safeguarding, and we did not see evidence that midwives had achieved these in the training provided by the trust. This could lead to adults safeguarding needs not being recognised and met. Staff only had access to 1 member of staff trained to level 3 adults safeguarding for advice, outside of the safeguarding team. Medical staff achieved 67% compliance in level 2 and 3 safeguarding for adults and 69% compliance in level 3 safeguarding for children and young people. Recent figures provided by the trust showed an improvement in medical staff compliance with level 3 adult safeguarding training.

Staff followed safe procedures for partners and families visiting the wards. The service strictly controlled access to all areas. All other visitors used a doorbell to alert staff they needed to enter. Staff challenged unauthorised persons and ‘tail gating’ (when a person tried to enter with another person who had permission to enter or exit the area) was not permitted.

Staff undertook baby abduction drills, the last drill was in December 2024, so they knew what to do in the event of an attempted baby abduction. The service had a baby abduction policy; however, 4 members of staff we spoke with were not aware of the policy or the procedure involved if a baby had been abducted. The trust had appropriate safeguarding policies that aligned with national guidance. Staff received training specific to their role on how to recognise and report abuse. Staff were additionally aware of specific safeguarding issues that were related to maternity services and newborn care. These included Female Genital Mutilation (FGM), child sexual exploitation (CSE) and coercive control. The service had a domestic violence specialist midwife to support women and their families.

Staff described a supportive and available safeguarding team. The safeguarding midwife visited the wards daily and the wider team were always available for advice. The safeguarding team also had clear escalation pathways and reported to the board via the hospitals safeguarding lead. Staff completed assessment for women to identify and support those at risk of self-harm and suicide.

Staff placed a flag on women’s records if safeguarding issues were identified. This included staff in the emergency department and the early pregnancy unit (EPU). This allowed staff to easily identify women or babies at risk.

Women who did not attend hospital appointments were flagged to the community team for follow up. Women were highlighted and discussed during risk meetings to ensure they were contacted if they regularly missed appointments.

Staff gave examples of how to protect women from harassment and discrimination including those with protected characteristics under the Equality Act 2010. Staff understood the importance of supporting equality and diversity and ensured care and treatment was provided in accordance with the Act. Specialist midwives supported women with protected characteristics including women from traveller communities.

The evidence showed significant shortfalls. The service did not always work well with people to understand and manage risks. Staff did provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff used cardiotocography (CTG) to monitor babies' wellbeing. A CTG is used to monitor the fetal heartbeat and uterine contractions during pregnancy and labour and can identify if a baby is in distress. The trust had a policy outlining the frequency and review process for CTG (including fresh eyes). We saw that the recording of fresh eyes was not always consistent and that the use of both a digital record and paper copies of CTG could lead to incomplete recording. Staff used two processes for recording and storing of CTGs. One system was central monitoring where electronic CTGS were recorded, it allowed the CTGs to be accessed and reviewed across the trust and recorded an audit trail. The other system was the electronic patient record. There was a requirement to record actions and events on the CTG which could not be done digitally. Staff made notes on the paper CTG trace, which needed to be scanned by the administration team and attached to the digital patient record.

The service had a policy and process for the recording, annotating and storage of CTG traces. During our assessment clinical staff were unable to tell us if the information was in the trust policy or what the exact process was.

Recording of CTGs was raised with an external IT company however, there were delays in achieving a fix for the issue. Managers had also raised the concerns with the divisional director of IT.

The trust carried out a CTG Fresh Eyes Deep Dive 21 November 2024 (data collected in September 2024). The audit found inconsistency in documenting, reporting and recording of ‘fresh eyes’ across the trust. At RSCH trust policy indicated a peer review form should be used to document fresh eyes, however, it was noted that its use was not fully embedded. On assessment we found that this was still an issue.

Staff told us there was a digitalisation programme in place, but they were unclear when this would be completed. In December 2024, a joint digitalisation protocol had been agreed with all trust sites however, there was no timescale for completion.

There was no prioritisation tool or risk assessment to support the effective prioritisation of women awaiting induction of labour (IOL). We reviewed the recently updated guideline (awaiting approval) and there was no inclusion of a prioritisation tool.

Staff worked to an agreed timescale for each stage of the IOL pathway. The lead midwife contacted women directly if delays were anticipated to advise, explain the reasons why and offered an apology.

Staff recorded information on delayed IOL on the department staffing acuity tool. Staff had raised concerns about the number of delayed IOL and anxiety about the impact this had on workload and ability to offer individualised care. In response an IOL discussion group had been formed to listen to their concerns and explain emerging plans and next steps. However, there was no formal incident reporting or recording of delayed IOL to monitor the impact of delays.

In the records we reviewed there was no documentation on patients level of risk in relation to induction, or the acuity and capacity within the unit. There was no record of any option to transfer to another unit with availability for inductions. Staff told us there was opportunities to transfer women to other units within the trust, which was discussed at the daily staffing huddle.

Staff used national tools to assess women during the antenatal period. A full assessment was completed at their booking appointment (the first full assessment at the beginning of the pregnancy).

A fetal monitoring team ensured staff were updated on fetal monitoring guidance and ensured staff had undergone training in this area. The team covered all areas of the maternity unit and staff told us the team would come out of hours to ensure equity of access to learning.

Staff changes and handovers included all key information to keep women and babies safe. We saw handovers and safety huddles included key information needed to keep women and babies safe. Each staff member had an up-to-date handover sheet with key information recorded.

Women received a physical and emotional risk assessment before discharge and were given the contact details of emergency services, the health visitor and infant feeding groups. Doctors working in the triage department or labour ward reviewed any mothers readmitted after being discharged home. Health visitors and GPs were also informed of the discharge.

The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. Staff did not make sure that equipment, facilities and technology supported the delivery of safe care.

The service provided a full range of maternity services. This included antenatal, triage, early pregnancy unit, postnatal wards (including transitional and HDU beds) labour ward,1 obstetric theatre, recovery area and a bereavement suite.

However, the design and the environment did not effectively meet the needs of women and babies. There was only one dedicated obstetric theatre which was not in line with national guidance which recommended two obstetric theatres to be available for safety of women and babies. The trust had conducted a pilot in July 2024 to have a permanent second theatre. Staff reported that the pilot had been successful and welcomed the introduction of a second theatre. However, the pilot finished in August 2024 and there was still no permanent solution. This meant that if a second theatre space was needed, for example in an emergency, women would be transferred via a separate lift to the main theatres down on level 5. This could lead to delays and could take staff away from the main unit if a transfer was needed. From February 2024 to February 2025 the emergency theatre was used 20 times.

Staff told us that women who were scheduled for elective caesarean section were often delayed. We reviewed data collected from October 2024, this showed that 20 women had their elective caesarean section delayed by at least 1 day, 3 of these cases had a delay of 3 days. The data showed that 5 women were transferred to another maternity unit within the trust. The same data showed 69 women in the month of October 2024 had a delayed start time for their caesarean section. Women were told to be nil by mouth from 6 in the morning of their planned procedure. Of the 69 women who had a delayed theatre time 48 women were not taken to theatre until after 1pm, with 17 women being delayed until after 4pm.

Antenatal clinics, specialist consultant run clinics and routine sonography scans were held in a separate building called Sussex House. This was a 10 -15-minute walk from the main maternity department. The building needed repair. We saw three broken windows repaired by tape being placed across them, staff told us they had been reported.

The main lift within the department was broken, staff had reported this twice the most recent time was in December 2024. The clinics were held on a lower floor of the building so if women on beds or neonatal transport cots needed to be transferred out of the building there was no immediate way to do this. Currently the patients would be moved through the clinic to a side door leading out to a ramp and access point for an ambulance. This area had rubbish and debris in, and staff told us that they had also had problems with members of the public sheltering there. Staff had reported security concerns related to access and break-ins which had been on the department risk register since October 2024. There had been improvements with CCTV installation but not all risks were mitigated.

Staff told us they did not feel safe leaving and arriving for work at Sussex House particularly in the winter months when it was dark. We spoke with several members of staff who all expressed concern over the location, safety and environment in the building.

We spoke with the head of security for the trust who was aware of both security incidents. They told us there was CCTV installed and that additional bolts had been placed on the back doors. However, there was an incident reported regarding two broken window latches in one of the rooms which would have enabled access to the building. This was reported to the maintenance team as a high priority in October 2024 and was still an ongoing issue at the time of assessment.

The Early Pregnancy Unit (EPU) was located on level 11 of the Thomas Kemp building. There was limited space available, staff told us the lack of space was challenging and that on occasion women were being told bad news in the doctor’s office as there was no available quiet place to tell them.

The location of the maternity services meant that women and birthing people had to take a lift to level 12 and 13. Whilst on site we witnessed delays and malfunctioning of lifts.

The department did not have a fire safety warden available on each shift. Staff were trained in fire safety, however, the nature of the department being on the upper floors of a tower block means that the risks associated with a fire breaking out were higher. Following our assessment the trust has appointed a fire officer to lead on ensuring a trained fire warden was available on each shift.

The service did not always detect and control potential risks in the care environment. A patient safety alert issued in 2020 highlighted that services providing mental health care routinely develop environmental improvements and safe management during clinical care to reduce the risk of self-harm or suicide. Staff told us that ligature risk assessments had not been completed, and someone had been tasked to look at this trust wide. There was a trust wide programme of replacement of pull cords to ensure they were all ‘Low ligature risk’. A ligature cutter was stored safely and available to staff if needed. We requested evidence of environmental ligature and ligature point risk assessments and we were not immediately provided with this. There was no evidence of this being documented on the risk register. Following inspection, we were provided with evidence that a standard operating procedure (SOP) and risk assessment had taken place in August 2025.

Staff mostly disposed of clinical waste safely. Waste was segregated correctly and stored securely while awaiting disposal. Sharps bins were assembled correctly however, in five rooms we looked at the sharps bin lid was not closed, and 2 bins had been overfilled, and sharps could have been accessed by patients.

There were sufficient numbers of resuscitaires throughout labour ward. The resuscitaires were stored outside of the labour rooms where appropriate to make the rooms feel less clinical. Staff reported no delay in moving the resuscitaires into the rooms as needed, if mothers were higher risk they were placed in the rooms beforehand.

The service ensured regular checks of specialist equipment in including resuscitaires and resuscitation trollies. We checked all resuscitation and emergency trollies across the unit during our assessment they were fully equipped and monitored daily. A central team monitored all the trollies across the trust and monitored any gaps in checks which were escalated to the head of midwifery.

Equipment and technology were well-maintained and support staff to deliver safe and effective care. We checked 15 pieces of equipment across the department which had been tested and had dates for re-testing in clear view.

The evidence showed some shortfalls. The service did not make sure there were enough qualified, skilled and experienced staff. Staff received effective support and supervision. Staff worked together well to provide safe care that met people’s individual needs.

The department recognised the impact of short staffing on the workforce and implemented a new divisional clinical operating model which included overarching cross site clinical director roles for both specialities alongside dedicated site-specific medical leadership.

The trust had completed a staffing review in 2023 using a nationally recognised acuity tool. There is no recognised national midwife to birth ratio to benchmark against currently. The trust had set the current midwife to birth ratio at 1:22. The actual versus planned staffing levels were achieved on average 85% of the time.

Acuity was measured on a four hourly basis and the service used a specific workforce tool. The complexity of the cases on labour ward at the time, and the available staffing were entered to calculate acuity. At the time of inspection there was a 11% vacancy rate for midwives at RSCH, this was an improvement from the summer of 2024 where the vacancy rate was on average 16%.

The service did not have a dedicated doctor in the triage lounge in line with recommendations. There was always a consultant on site. However, the consultants worked across several departments and staff reported this could lead to delays in women being seen. On the day of assessment, we saw women delayed in triage, postnatal wards and across other areas, as consultants had been called to assist an emergency in the emergency department. Staff told us that there were frequent delays in non-urgent medical review due to the consultants having to cover several areas across the hospital. Between February 2024 to February 2025 there was one reported incident of a delayed medical review in Maternity at RSCH.

An escalation policy was used to support the service at times when the staffing did not meet acuity. During the summer of 2024 significant mitigations were used to increase clinical staffing, including specialist midwives being used clinically as well as matrons and labour ward coordinators. Labour ward coordinators were supposed to be supernumerary; these staff should not be providing 1:1 care to women and people in established labour. However, as part of the escalation policy these staff members could be called to work clinically. This was marked as a ‘Red Flag’ incident and captured as part of acuity reporting. Red flag data forms a part of a monthly report shared within divisional governance meetings and monthly maternity safety champion meetings.

There were 14 episodes of 1:1 care provision by labour ward coordinators between May 2024 and August 2024. Staff reported this had improved as staffing levels have increased.

Mandatory training figures were mostly in line with the trust target of 90% for nursing and midwifery staff. However, medical staff had worse compliance with none of the mandatory training figures were in line with trust targets. Some compliance figures were well below the expected targets. Fire safety training compliance was only 55% and adult life support and infection prevention and control compliance was 67%. The highest compliance was health and safety training, but this was still below the target of 90% with reported training at 75%. We saw this had been highlighted in meetings and staff we spoke with said time restraints were the main reason for non-compliance. There was no action plan to address this shortfall at the time of inspection.

Practice development midwives arranged mandatory and maternity specific training which was delivered over a number of days. Each day included several topics in a face to face environment. Staff reported that they enjoyed the training days and they were good for team building as well as learning.

The service used bank staff to cover unfilled shifts. Managers requested bank staff who were familiar with the service and ensured they had a full induction and orientation of the area they were working in.

From April 2024 to January 2025 there was an average vacancy rate of 15% for maternity support workers (MSW). The trust indicated that several MSW had gone on to start their midwifery training which showed good career progression and support.

The service ensured staff were competent for their roles. Managers appraised staff performance and held supervision meetings, providing support and development. The appraisal rate for the maternity service was 82%. Newly qualified midwives had a 12 to 18-month preceptorship program, which supported them to transition from student to qualified midwives. Several staff mentioned that staff shortages and changes in the leadership team had meant that they had reported to different managers. However, staff felt supported to undertake further training when identified during the appraisal process.

The service had enough medical staff to keep women and their babies safe. The medical staff matched the planned number. The service had 22.63 whole time equivalent (WTE) consultant obstetricians with a vacancy of 1.73 WTE. There were 2.02 WTE Specialist and Associate Specialist doctors with a 2.01 WTE vacancy rate.

The service met the requirements of the Clinical Negligence Scheme for Trusts (CNST), Maternity Incentive Scheme. The requirements were met for year 5 and the trust was on track to meet the requirement for year 6. The department was also compliant (since September 2024) with the Ockenden requirement for ‘consultant present’ ward rounds day and night.

Consultants of different specialities such as anaesthetists, obstetricians and neonatologists had regular study days as a team, and they told us this had worked well to break down barriers and improve relationships.

The service had a good skill mix of medical staff on each shift and managers reviewed this regularly.

Managers could access locum doctors when they needed additional medical staff and ensured locum doctors had a full induction and orientation of clinical areas before they started work.

New staff were required to undertake a local Induction as well as statutory and mandatory training. Clinical staff were required to undertake an appropriate clinical induction which incorporated basic life support, manual handling and emergency situations. Competency assessments were then undertaken and signed off by line managers.

The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. Staff did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. Oversight and governance of cleaning schedules, was not always effective.

Matrons and ward leaders oversaw infection prevention and control across the maternity department. However, cleaning schedules and records were not reviewed effectively to monitor for themes and trends. For example, there was no regular review or audit to check for non-compliance. Staff did not complete a checklist; they followed a list but did not mark each area of compliance therefore there was no formal way of understanding (for audit purposes) if an area had been checked correctly. Staff marked a whiteboard after the check to say they had completed it, but there was no system to ensure that the process had been completed effectively.

Once a day the ward lead or matrons checked the whiteboard and entered the result on the daily tracker for compliance. Records we reviewed online showed the cleaning standards for the past 3 months had been mostly met. However, the results were not reviewed in any detail or monitored long term to check for themes. We saw that during a ‘Weekly Internal Observation Tool’ review in August 2024, on the labour ward, triage and post-natal wards the issue of reliable and auditable checklists was highlighted as a concern. Despite this the same system was still in use.

Staff told us they completed mandatory training on infection prevention and control annually and we saw most staff groups had completed this. Compliance for annual updates were 84% for midwives however medical staff had worse than the trust target with only 67%.

Staff followed infection prevention and control principles and used personal protective equipment (PPE). We observed staff washing their hands or sanitising them with antibacterial hand gel. However, we saw staff that were not bare below the elbow and some staff were wearing jewellery, which meant staff could not clean their hands and wrists effectively.

All areas in the maternity service seen were visibly clean and had suitable furnishings. Staff cleaned equipment after contact with women. Staff used ‘I am clean’ stickers to show equipment was clean and ready for use.

All visitors to the maternity department were prompted to clean their hands on entering the department.

The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

The service had policies and processes for the secure storage of medicines including controlled drugs and medical gases. However, we identified concerns with the management of the stock medicines we found items that were out of date and the governance to ensue checks were completed was not robust. Stock medicines are routinely kept in supply by a hospital ward or department, as opposed to "non-stock" medications which are only ordered when specifically needed for a patient.

The trust prepared emergency medicines boxes centrally. These were available, tamper evident and in date. Staff in the service prepared various medicines boxes to support the management of deteriorating patients. However, preparation of these boxes lacked governance and oversight which resulted in variation of content and inconsistent labelling. We found the medicines grab box on labour ward that contained out of date consumables and medicines with no evidence they had been checked.

Medical gases were not stored safely and lacked adequate signage. We saw two expired medical oxygen cylinders and were not assured that medical gas regulators had been serviced.

Staff supplied over labelled medicines against discharge prescriptions, also known as to take out medications (TTO’s). Over-labelled medicines are those that have been labelled with pre-printed instructions, like dosage information, on top of the original packaging. However, the quality of the over labelling of the medicines in the TTO cupboard varied including appropriate over labelling, labelling obscuring the directions and incomplete labelling. There was a risk that women may be discharged with medicines that had incomplete labelling and directions.

The service monitored staff exposure to nitrous oxide when working in the delivery suite. Nitrous oxide, commonly known as "gas and air," is used as pain relief during labour. While short-term exposure is generally safe for patients, for midwives and other staff who spend extended time in labour rooms may experience higher exposure levels, potentially leading to long-term health problems.

The trust provided guidance to staff to support the record keeping of controlled drugs and controlled stationary. Staff followed trust guidance in relation to controlled drugs registers.

Midwives administered an agreed list of medicines via "midwife exemptions" and patient group directions (PGDs). These were guided by legislation and supported by trust guidance. We reviewed 6 PGDs and saw that 1 national PGD had been approved for local use. However, a more recent version had been released which meant the locally approved version was out of date during our assessment.

The service had ad-hoc pharmacy support therefore, risk-based pharmacy support was not available to support high risk pregnancies with pharmaceutical care plans. A pharmaceutical care plan involves healthcare professionals working in partnership with patients to agree a plan regarding their medicines. There was also no regular pharmacy support to undertake medicines reconciliation, supporting safe medicines use in breastfeeding post-partum, clinical screening of discharge prescriptions and timely transfer of information to primary care. Medicines reconciliation is the process of identifying an accurate list of a patients current medicine.