Princess Royal 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 that women were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination.

At our last assessment we rated this key question requires improvement. At this assessment, the rating of safe remains requires improvement. This meant 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.

The service remained in breach of regulation 18: staffing. We found staff were tired and burnt-out due to workforce pressures and the demands of the service. Shifts felt increasingly overstretched for staff and staff sickness rates were high due to stress. There was a lower number of consultants working within PRH compared to the other maternity locations across the trust.

We found a breach of regulation 12: safe care and treatment, we found women did not receive a midwifery review within 15 minutes of arrival within the maternity care centre and women did not receive a medical review within a timely manner. The service had 1 obstetric theatre which was frequently reported to be closed due to ongoing equipment failures and issues with the heating and ventilation. There were gaps identified in the medicines record keeping books, where the anaesthetic team had not signed to identify drugs which had been administered to women in theatre.

However, the service used past anonymised incidents and complaints to support staff in their training. Vulnerable women were supported throughout their pregnancy and birthing journey with a ‘one stop clinic’ and there was a pathway to support perinatal women during a psychiatric emergency. A psychiatric emergency is where a person experiences a mental health crisis and needs immediate support.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We scored the service as 3. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff knew what incidents to report and raised concerns. Staff reported incidents and near misses in line with the trust policy. The service used national risk tools, Patient Safety Incident Response Framework (PSIRF) and a Perinatal Quality, Safety Risk Framework to review and monitor risk.

The patient safety team had oversight of the grading and reviewing of incidents and there was a clear system to investigate incidents and identify learning, using the PSIRF model. PSIRF was embedded within maternity and learning from incidents was shared with maternity teams, through email alerts and messages during daily handover.

There was also a restorative culture programme in place, offering structured support for staff involved in challenging incidents or investigations. A restorative culture programme promotes a supportive, open environment that focuses on learning, reflection, and improvement rather than blame when issues arise. It encourages honest dialogue, accountability, and positive working relationships.

The perinatal mortality review tool (PMRT) is a tool to support objective and standardised local reviews of care if a baby dies. Between April 2025 to June 2025 the service had 1 PMRT case.

Quarterly PMRT reports were submitted to the trust board and cases submitted to Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries (MBBRACE) within 7 days of a baby’s death and duty of candour was given to all families.

MBBRACE is a national programme focusing on improving maternal and infant health. Questions and feedback received from women and their families were presented to the PMRT review panel and as part of the review the trust responded to questions raised. PMRT reports were reviewed by a multidisciplinary team.

The service engaged with the Maternity and Newborn Safety Investigations (MNSI) programme. There were 3 incidences reported to the MNSI for investigation within the 6 months before the inspection, with 1 assessment completed.

There was no common theme reported for the MNSI cases, however, there were concerns around safety and delay in treatment.

A multidisciplinary (MDT) or obstetric review of incidents was held weekly. For Princess Royal Hospital there were around 4 incidents a week to be reviewed by the team. In addition to these reviews the patient safety midwives met with ward leads weekly to discuss incidents which did not require an MDT or obstetric review. Community incident reviews were twice weekly and was community focused only.

The team at Princess Royal Hospital did not keep formal incident review minutes, instead outcomes were provided on the electronic incident reporting system. Following the review of incidents, learnings and actions were shared with the wider team through the maternity message of the week and discussed further within the safety and quality meetings.

Monthly situation, background, assessment and recommendation (SBAR) learning from incidents was shared with all staff and displayed on safety and staff notice boards throughout the unit. Maternity staff had access to a team’s channel which contained incident reviews, improvement plans and tools could be accessed.

Anonymised incidents and complaints presented within the maternity governance meetings and local maternity and neonatal system (LMNS) quality and safety meetings were used during trust maternity mandatory training.

We scored the service as 2. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Systems and processes within maternity triage were not embedded to ensure women were safe. The service was not consistently meeting the target for women to receive an initial review by a midwife within the maternity assessment unit, and women were not always prioritised appropriately.

The maternity assessment unit (MAU) was the service’s maternity triage area. The MAU is an urgent 24-hour service to assess and treat pregnant women where there were urgent concerns. Midwives used a nationally recognised tool to rate risks consistently. Monthly audits were completed to determine how long women waited for an initial assessment and if they required a medical review.

The MAU standard operating procedure set the target for women to be seen and assessed by a midwife within 15 minutes of arrival. The service did not meet the trust compliance of 90% to see women within 15 minutes. The service provided the data for 2 months which showed 79.4% of women were reviewed within 15 minutes in August 2025 and 78.9% in September 2025. This meant there was a continued risk to mother and the unborn baby by not identifying or addressing potential concerns quickly.

At the time of our assessment the MAU was staffed with 1 band 6 midwife, 1 band 6 peak midwife and 1 maternity support worker. The peak midwife was in place to support the MAU during peak times, when more women attended.

Staff told us the peak midwife was often redeployed from MAU to cover other areas within the unit which impacted greatly on women being seen for a timely review. This was not in line with the Royal College of Obstetrics and Gynaecology guidelines.

Women also experienced delays in receiving a medical review within MAU. Although there was no mandated target for the trust to achieve for women to receive a medical review, there was an ongoing risk to women who were not seen by a doctor in a timely manner. Data showed the number of women seen for a medical review within the expected timeframe on average between April 2025 to September 2025 was 46.8%.

We raised concerns with senior leaders following our assessment regarding the low compliance rate for women being seen within the specified timeframe by a midwife or for a medical review. The service was responsive and staff were told the peak midwife was not to be redeployed from the MAU. This had led to an improvement in the 15-minute triage compliance, with 79.6% of women being seen within 15 minutes in November 2025 and 82.4% December 2025. A review of peak midwife shifts showed the peak midwife had not been redeployed on any shift in December 2025 and the service leads was to continue to monitor the triage compliance and adjust staffing as required.

The service had also introduced a doctor daily on each shift within MAU which had led to improved timely reviews of women. For example, 16.7% of women were seen within 1 hour in November 2025 and following the medical daily allocation this had improved to 55.6% in December 2025. The service was completing improvement work to increase accurate reporting of times when women had received a medical review.

Although there were delays in reviewing women due to staffing within MAU, we did find staff were trained to respond to risk and were able to identify and act when women were at risk of deterioration. Staff completed risk assessments and took action to remove or minimise risks, and documentation was completed appropriately.

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 2025. It is CQC coordinated with other stakeholders, but it is reported by us at CQC.

We reviewed the latest findings of the maternity survey 2025. We saw that when women were asked “Thinking about the last time you contacted the telephone triage line, did you feel that you got the advice you needed?”, the service scored 8.9, which was above the national average of 8.3 when compared to all other trusts in England. For the question “Thinking about the last time, you attended triage face-to-face, did the midwife or doctor you spoke to listen to you?” the service score 9.1, which was above the national average of 8.7.

Staffing pressures meant labour ward coordinators were not consistently able to maintain supernumerary status. Data showed 60% of red flags were due to coordinators providing clinical support during shifts.

The labour ward coordinator not being supernumerary was worse at Princess Royal Hospital compared to the other 3 maternity locations within the trust. Staffing red flags in maternity care can identify a lack of adequate maternity staffing, which can lead to unsafe care for women and their babies. Red flags may also occur due to staffing shortages, which can affect the ability to provide safe care.

Staff attended two cross-site daily status meetings each morning where they discussed the current and emerging situation at both Princess Royal Hospital and Royal Sussex County Hospital. Meetings were chaired by the director of midwifery or head of midwifery. The agenda included staffing, bed capacity and learning from recent incidents.

The second meeting covered all four hospital sites 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 assessment we attended handover meetings and safety huddles and we found them well attended and used to fully discuss women and any emerging concerns.

The service provided a centralised maternity telephone triage which received calls for all four of the trust maternity locations.

The LMNS insight visit in August 2025 recognised the improvement of the centralised telephone triage service with no further maternity and newborn safety investigations linked to telephone triage. This included a reported 40% reduction in born before arrival cases. This meant there was improvement to women accessing advice and reducing avoidable risks for women.

Transitional care for babies provided extra support beyond the usual postnatal care, where babies were well enough to be cared for at the bedside with their mother. Care for transitional care babies were provided by the midwifery and neonatal teams and all babies were reviewed daily by the neonatal team.

Staff completed newborn risk assessments using recognised tools such as the Newborn Early Warning Trigger and Track (NEWTT) tool to record observations and feeding. All babies who needed special care or transitional care were discussed at an avoiding term admission into neonatal units (ATAIN) meeting. The ATAIN meeting focused on avoiding term admissions into neonatal units for babies over 37 weeks gestation, by identifying and addressing potential issues.

We scored the service as 2. The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

During the assessments of the four maternity service locations, it was identified that the trust did not follow the Intercollegiate Document for Safeguarding Children and Young People 2025 or the Royal College of Nursing adult safeguarding: roles and competencies for health care staff (2024/2025) guidance, which sets out that health care staff engaged in assessing, planning and delivering care should be trained in adult level 3 safeguarding.

However, since the inspection the trust had introduced a rolling programme of level 3 adult safeguarding training to midwives and obstetric teams.

Data showed at the time of our assessment there were no midwifery staff trained to this level. Medical staff did not meet the trust requirement for level 3 safeguarding children’s training with 86.9% compliance. Midwifery compliance was over the trust target of 90% and was 93.3%.

Staff told us they had access to the safeguarding lead midwife, and they visited the unit daily to offer support or guidance and to determine whether there were any women who required support.

The safeguarding team had clear escalation pathways and reported to the board via the hospitals safeguarding lead. Staff completed assessments for women to identify and support those at risk of self-harm and suicide. During a review of women’s maternity records, we saw staff asked safeguarding questions at each antenatal contact if safe to do so.

Staff placed a flag on women’s records if safeguarding issues were identified. This included staff in the emergency department. 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 discussed at risk meetings to ensure there was a follow‑up contact when appointments were frequently missed. Where concerns or ongoing non‑engagement were identified, appropriate safeguarding referrals were made to external agencies.

The trust had appropriate safeguarding policies that aligned with national guidance and a designated safeguarding midwife. Staff understood and could describe how to protect women from abuse and could give examples which demonstrated their safeguarding understanding. Staff could recognise and knew how to report abuse.

Staff followed safe procedures for partners and families visiting the wards. The service strictly controlled access to all areas. Staff undertook baby abduction drills, so they knew what to do in the event of an attempted baby abduction. Staff told us there had been a baby abduction drill within the last 12 months.

The service supported vulnerable women throughout their pregnancy and birthing journey with a ‘one stop clinic’. The clinic saw women with substance misuse and were provided support from the obstetric, safeguarding, smokefree pregnancy and paediatric teams.

There was a pathway to support perinatal women during a psychiatric emergency. Postpartum psychosis is a severe mental illness which can start suddenly during the final trimester of pregnancy or in the days or weeks after having a baby.

We scored the service as 2. The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The trust reviewed Cardiotocography (CTG) monitoring and intermittent auscultation through completing ‘fresh eyes’ to gain reassurance of staff competence and completion. Cardiotocograph (CTG) and intermittent auscultation was a method of fetal monitoring during labour that involves listening to the fetal heart with a doppler ultrasound.

The electronic record system showed the compliance rate for completing ‘fresh eyes’ monitoring was below the trust compliance with only 10% to 20% compliance.

The service completed a paper review of ‘fresh eyes’ to identify any potential issues with pulling information through within the electronic data system. However, the paper review still showed poor compliance of fresh eyes and there were inconsistencies within staff documentation.

‘Fresh eyes’ provide an independent and objective assessment, which is essential for improving the safety of women and reducing the risk of errors in the interpretation of fetal wellbeing during labour and supporting safe and timely clinical decision‑making.

Themes of non-compliance for completion of ‘fresh eyes’ were related to activity in the service such as delays in completion due to handovers, epidurals being sited or being transferred to theatre. Despite the service not completing hourly ‘fresh eyes’ reviews, the service noted escalation of care was always appropriate. The maternity audit team were in the process of implementing a deep dive audit to gain a greater understanding regarding the poor compliance.

Hypoxic-ischaemic encephalopathy (HIE) is a term for a brain injury that happens before, during, or shortly after birth when oxygen or blood flow to the brain is reduced or stopped. We requested the number of cases of HIE within the last 3 months from the trust, and were provided with data that calculated both suspected and provisional HIE rates rather than confirmed diagnoses. HIE rates were 0 for June 2025, 10.31 for July 2025 which was way above the national average of 4.25 and 0 in August 2025. Following the reporting process the service reported the 12-month rolling rate for suspected HIE cases for July 2025 was reported to be 2.74/1000 births. However, the service did not provide the updated confirmed number of cases.

The service reported HIE rates had increased from September 2025, and the service reported they were completing thematic reviews into the increased rates. However, HIE rates between September 2025 to November 2025 were not provided by the service as this data had not been reviewed or approved by the trust board.

The service did not have a risk assessment for only having 1 obstetric theatre and there was no standard operating procedure for when the service used the main theatres for extra caesarean section lists.

The second emergency theatre cover at night relied on an on-call team based off site. There was a 45-minute response time, which was identified by the service, to be unsafe and not able to meet the urgent response times for an emergency caesarean section. This was on the maternity risk register for the site. Governance processes to manage incidents for when the obstetric theatre was not accessible, included MDT planning meetings, flowcharts and SBAR documentation for each incident, with mitigations.

We shared our concerns regarding the regular closure of the obstetric theatre and high number of caesarean sections to senior leaders. Senior leaders shared the concerns raised to board and presented the information to the clinical transformation programme regarding theatre capacity. The outcome was for a 2-day theatre list in main theatres to start in March 2026 to accommodate the high number of elective caesarean sections. Staffing would be funded by the programme and will be separate to the maternity staffing establishment. The labour ward theatre had been prioritised for ventilation and heating improvement work and improved governance processes were in place to manage incidents when the labour ward theatre was not accessible. This included MDT planning meetings, flowcharts and SBAR documentation of each incident and mitigations.

Women attending the service for an induction of labour (IOL) were given an initial date for admission to start the induction process. Women were advised that this date may change based on acuity and the prioritisation according to clinical risk.

Information received from staff identified that there were regular delays in women receiving the IOL. We requested the number of IOL delays and times of waits between May 2025 to November 2025 for the hospital. We were told the service did not collect data regarding the waiting times and to identify the information would mean a review of women’s case notes.

The service had recently updated their clinical guidelines and formed an IOL discussion group to listen to concerns and to explain emerging plans. However, without collecting waiting time data, the service could not clearly identify reasons, themes or trends for delays in induction of labour to improve women’s experiences and to fully alleviate risk.

The risk assessment (RAG) rating at birth tool was embedded within the electronic patient records and all babies were risk assessed within the first hour of birth. This identified whether babies were low or high risk at birth. This supported the identification of early onset of sepsis and babies who were higher risk of clinical deterioration.

Documentation audits were not completed as a standalone audit, instead the service completed a maternity incident review process which looked at the maternity journey of the woman. Any failures identified within the documentation practice triggered a shared learning review. The service recognised that this was not a usual documentation audit, noting specific triggers. However, they felt it provided assurance about practice within maternity as well as identifying trends.

There were around 4 incidents a week at Princess Royal Hospital which required an MDT review. Patient safety midwives met with ward leads weekly to discuss incidents which did not require an MDT review.

We scored the service as 1. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The service provided a full range of maternity services. Maternity services included, antenatal clinics, maternity assessment unit, day assessment unit, labour ward, 1 obstetric theatre, recovery area and a bereavement suite. The service did not have a midwifery led birthing unit.

We found the design and the environment did not effectively meet the needs of women and babies. The service had multiple estates issues which made it difficult for staff to deliver timely clinical care safely and contributed to a more stressful working environment.

For example, the service had only 1 dedicated obstetric theatre, which was used for both elective and emergency caesarean sections. The risk of having only 1 dedicated maternity theatre meant there were significant risks to the safety of mothers and their babies, as it left no contingency for emergencies that were happening at the same time.

The service had worked with main theatre to run a series of elective caesarean section theatre list; this was to support with the demand of women having elective caesarean sections as part of a waiting list initiative.

We found the obstetric theatre was often closed due to ongoing equipment failures and issues with the heating and ventilation. From November 2024 to November 2025 the theatre had been closed 45 times. Staff told us that theatre closures occurred frequently each week. They also stated that the reported figures did not include short‑term closures while waiting for the theatre to reach the required temperature. Staff told us due to the short time of closure this was not recorded as an incident.

Maintaining the correct temperature in obstetric theatres is essential for the safety and comfort of women and their baby. The temperature and humidity levels in the theatre must be carefully controlled to avoid risks associated with anaesthesia and prevent the woman and baby from becoming too cold which could lead to hypothermia or cardiac concerns.

During the assessment the obstetric theatre was closed due to being at an inadequate temperature for surgery, the main theatre was unable to be used due to one of the main theatres being closed for repairs and the other theatres being in use. As a result, all elective cases were delayed, leading to longer waits for women and a significant risk of theatres being unavailable for emergency caesarean section cases. We saw this have a negative impact on women and increasing their anxiety around the procedure.

The main theatres were 2 floors lower than the obstetric theatre and staff had priority passes for lifts to ensure transfers were managed in a time-appropriate way. However, lifts were situated in public corridors which did not maintain the privacy and dignity of women being transferred. During our assessment we also observed that one lift was out of order which would delay the transfer and movement of women within the maternity unit. The use of public lifts and reduced lift capacity, risked compromising privacy and dignity and delaying transfers, including in emergencies.

We raised concerns regarding theatre capacity and the temperature, ventilation and capacity issues within the obstetric theatre to the senior leadership team following the assessment and they took immediate action. An options appraisal was presented to the clinical transformation programme board on 5 January 2026. The outcome was to have 2 all day weekly theatre sessions in main theatres to accommodate 10 caesarean section cases.

The obstetric theatre was also prioritised for ventilation and heating improvement work, with work to start in April 2026.

The MAU did not have enough CTG machines for each assessment bay area and at times the unit had to borrow machines from the labour ward. There were not incidents identified which related to a lack of CTG machines, however, not having enough CTG machines available meant there was a potential risk of delay in women being appropriately monitored.

We saw areas of the labour ward cluttered with equipment, which meant there was a possibility of contamination of equipment, difficulty in effectively cleaning the ward and hazardous in an emergency. Staff completed daily checks on specialist equipment, including the post-partum and major obstetric haemorrhage trolley in labour ward. The emergency resuscitation trolleys and resuscitaires were tagged, clean and appropriately stocked.

Fire exits were clearly marked and unobstructed. There were birth pool evacuation nets and equipment in every room that had a birthing pool.

The service had a purpose-designed bereavement area to help support women and their families. The bereavement area was located on the labour ward, along a separate corridor from the delivery suite. This provided a quiet, private, and sensitive environment where women and their families could create memories and spend time with their baby while grieving.

We scored the service as 2. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The service 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.

Staff told us they felt tired and burnt-out due to workforce pressures and the demands of the service. Shifts felt increasingly overstretched and sickness rates were high with 8% midwifery sickness, we were told this was mostly due to staff stress.

Staff told us there were not enough staff to manage the separate elective caesarean section list within main theatres. Senior leaders told us the separate theatre lists were staffed fully by the funding within the waiting list initiative. This meant midwives and support staff were brought in specifically for these maternity lists and the labour ward did not lose midwives to cover the extra theatre activity.

However, staff told us that although there were separate staff rostered for the extra theatre lists, senior leaders did not consider the impact on the flow and capacity within postnatal ward. This meant there were issues with the flow and capacity across the postnatal ward alongside caring for a larger number of women having elective caesarean sections. Staffing issues meant the extra theatre lists affected their ability to manage workload demands, respond to incidents promptly and provide safe care.

The service had 3 substantive consultant posts appointed in mid-September for Princess Royal Hospital (PRH), which were fixed term contracts. In line with current guidance, the requirement was to provide a twice daily consultant ward round. The service reported within the perinatal workforce report that this had been challenging at PRH due to vacancy and job planning restrictions. This meant consultants had attended ward rounds remotely, however, consultant ward round attendance was now being embedded into the service and attendance was improving.

There was a lower number of consultants working within PRH compared to the other maternity locations across the trust. This meant there was a challenge in ensuring equitable access to consultants which could impact on care delivery, escalation support and clinical oversight across the maternity service.

The service at the time of assessment was completing a Birth Rate Plus (BR+) assessment to assess the midwifery and maternity support worker workforce. The report was due to be completed in January 2026. The current staffing model for the service was reflective of the previous 2023 recommendations. The BR+ assessment is usually completed every 2 years. A BR+ assessment is an evidence‑based tool used to determine midwifery staffing requirements based on birth activity and case complexity. It supports safe staffing by ensuring workforce levels are aligned with clinical demand and risks to safe care are identified.

A staffing review of PRH identified staffing had been challenging between May to August 2025 which was reportedly due to short-term sickness, and vacant band 5 posts. This meant there was a challenge in staffing across the maternity unit and Princess Royal Hospital were not meeting the 85% trust target for adequate number of maternity staff to meet the needs of women.

The trust had recruited 2 full time band 8a recruitment and retention matrons to support maternity and neonatal services with safer staffing. The perinatal development workforce report identified the current vacancy data across maternity services and what short-term and long-term strategies were being put in place to support staffing.

Student midwives across the trust were offered a permanent position at their chosen trust location, which would over-recruit against current establishments. These hours would have been previously covered by bank and agency, with agency to stop and the number of bank shifts to be reduced. However, it was too early for the service to know if this had a positive effect on staffing at Princess Royal Hospital.

Newly qualified midwives completed a 12 to 18-month preceptorship programme, to support them in their role.

The current midwifery vacancy rates were 7%, however, with several midwives moving from hospital to community-based roles between May 2025 and June 2025, the vacancy rate increased to 10%.

The service did not provide the mandatory training figures for maternity and medical staff; therefore, we could not ascertain whether staff were up to date with key mandatory skills.

The trust provided Practical Obstetric Multi Professional Training (PROMPT) which was evidence based multi professional training package for obstetric emergencies including fetal wellbeing and competencies. All maternity and obstetric staff other than consultants were compliant in fetal well-being training. There were 89% of consultants completed the fetal wellbeing training day, however, only 67% had completed the e-learning training.

There were only 51% of the midwifery workforce since 2023 at Princess Royal hospital had completed the video-based training for pool evacuation. Within the last year there had been no live training of pool evacuation simulation training. Although there was no national benchmark for completing the pool evacuation training, the service could not be assured all staff were up to date and competent in how to evacuate a woman having complications safely from the pool. Senior leaders told us the team were working toward formalising expectations around pool evacuation training and to benchmark the frequency of staff training and compliance.

We scored the service a 2. 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. However, we saw there was oversight and governance of cleaning schedules.

Matrons and ward leaders oversaw infection prevention and control across the maternity service.

The service had recently introduced a specific maternity uniform policy. However, due to staff demands and ordering delays, uniforms were being distributed to staff gradually.

Maternity staff who were not yet provided with the new maternity uniform, wore hospital scrubs. We saw some midwives wearing the new uniforms, however, there were several maternity and obstetric staff wearing different coloured scrubs. This meant it was difficult to identify the role of staff. Staff we spoke with reported there were insufficient numbers of scrubs available and at times were wearing different coloured scrub tops to bottoms. Staff told us they often felt stressed as it was not always guaranteed they would have scrubs available for their shift and at times they have had to wear their own trousers whilst working. Although during the assessment we did not see this.

Band 2 and band 3 staff reported they were responsible for cleaning the labour suite rooms following a woman giving birth. However, they told us they had not received sufficient training or guidance on the effective cleaning of bodily fluids, which increased the risk of inadequate infection prevention and control.

We found cleaning schedules and records were monitored through audit to check for noncompliance. Hand hygiene across the unit showed maternity teams were 100% compliant.

We scored the service as 2. The service did not always make sure stock, and the administration of medicines was monitored appropriately.

There were gaps identified in the medicines record keeping books where the anaesthetic team had not signed to identify drugs which had been administered to women in theatre. This meant the risk of proper identification of administered drugs could lead to accidental overdoses or incorrect doses given.

Although there were policies and processes in place for the secure storage of medicines including controlled drugs and medical gases, we found this was not always followed. There were issues with the management of the stock medicines, with some out-of-date medicines and gaps in medication checks.

The service completed a controlled drug audit on a 3 monthly basis in line with best practice recommendations e.g. NICE guidance 46, Controlled drugs: safe use and management and the Duthie Report (1988, revised 2005) The Safe and Secure Handling of Medicines. Two months of audits were provided for both the labour ward and Bolney ward (antenatal and postnatal ward). All audits showed both areas did not meet the required target.

The service had medicine administration guidelines for midwives. Midwives had access to the full list of midwives’ exemptions, so they were clear about administering within their remit. Midwife’s exemptions allow registered midwives to supply and administer certain medicines without a prescription, under specific legal and professional conditions.

Staff were trained to administer medicines safely. Staff demonstrated good understanding of how to monitor for and manage medical emergencies that can occur in pregnancy, including post-partum haemorrhages and sepsis.