The Royal Bournemouth 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

This is the first assessment for maternity services since the move of services to The Royal Bournemouth Hospital. This key question has been rated as 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 women could be harmed.

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.

The service used national risk tools, Patient Safety Incident Response Framework (PSIRF) and a Perinatal Quality, Safety Risk (PQSR) Framework to review and monitor risk.

The top three patient safety incidents in the Safety Champions report in August 2025 were failure, insufficient, incomplete monitoring, term babies admitted to neonatal unit and post-partum haemorrhage.

Staffing and workload were reviewed daily by the senior midwifery team, and we were told actions were taken to ensure patient safety by following the escalation of maternity services policy. However, during the assessment and following a review of incidents, we found there were a number of concerns around low staffing and delays in women's care

The service reported the top three incidents within maternity on a clinical governance spreadsheet. These included post-partum Haemorrhage (PPH), term babies admitted into neonatal intensive care unit (NICU) and stillbirths. The service had taken action to drive improvements in these areas.

The maternity and neonatal risk and governance manager had overall oversight of the maternity and neonatal database for all perinatal mortality review tool (PMRT) which was updated by the PMRT midwife. All PMRT cases were reported to both the care group board and the trust board. They were also sent quarterly to the safety champions so they could check and challenge actions and make sure improvements were being made.

The service reported a higher number of still births than the national rate from April 2025 to June 2025. An initial review of cases carried out by the service had shown there had been a higher number of intrauterine (stillbirth) deaths in women from a black and brown ethnic background. The service planned to carry out a further review with a focus on women’s ethnicity and areas of deprivation to identify themes and trends and to drive improvement.

In August 2025 the service had 4 cases of neonatal deaths, with 2 incidents requiring escalation; these were a major obstetric haemorrhage and neonatal death. Top themes relating to patient safety incidents were delays in reviewing and actioning women’s results and delays in care postnatally. This meant there could be a delay in learning for staff and a delay in identifying safety improvements.

The service involved the Local Maternity and Neonatal Systems (LMNS) in safety incident reviews when appropriate. The LMNS is a partnership of people involved in maternity and neonatal services, working together to improve services. Regular monthly meetings with the LMNS allowed the service to provide information on emerging themes. For example, lessons learnt slides were presented to the LMNS by the maternity service, which showed how the service had responded to specific incidents and the areas where there was a requirement for improvement and learning.

Staff recognised and reported incidents appropriately and knew how to raise concerns in line with the hospital’s incident reporting policy. However, staff told us they did not always report incidents of low staffing levels or high acuity due to not having the time to do so.

Staff were able to explain the duty of candour. They were open and transparent and gave women and their families a full explanation when things went wrong.

The director of midwifery (DOM) presented the maternity and neonatal quality and safety report to the trust boards public meeting where a summary of all cases were given, alongside learning and themes throughout the maternity data.

We scored the service as 2. The service did not always provide safe systems of care and there were delays in the transition through the service. However, women were supported in decision-making, birth planning and treatment.

Systems and processes within maternity triage were not embedded to ensure women were safe. The service was not meeting the target for women to receive an initial review by the midwife and were not always appropriately prioritised. Monthly audits were completed to determine how long women waited for initial assessment and if they required a medical review. Since April 2025, the service did not meet the trust’s target of 80% for women requiring a medical review within maternity triage. Between February 2025 to August 2025 on average 72% of women received a medical review within the specified timeframe. To support clinicians with completing medical reviews, the service introduced an advanced clinical practitioner (ACP) into maternity triage. The service noted when the ACP was working within triage, 80% to 85% of women were seen within timeframe. The ACP worked across the maternity unit, working 8am-5pm mostly, with some lates, twilight and weekend shifts. However, the ACP covered only 12 shifts per month which meant that overall, the trust did not meet its target of 85% of women to be seen for a medical review.

The service had specialist midwives to support vulnerable women and consultant obstetricians were present for difficult births. Staff reported that it was easy to raise concerns and that they felt confident doing this. They also felt they had adequate training to respond to risks and were able to identify and act when women were at risk of deterioration.

During the assessment we attended staff handovers and found that staff used situation, background, assessment and recommendation (SBAR) to provide both a verbal handover and an up-to-date handover sheet, with all the key information needed to keep women safe. Multi-disciplinary (MDT) handovers and safety huddles were actively monitored for effectiveness and compliance.

Maternity key performance indicators measured the quality of care and outcomes for mothers and babies. The service monitored their performance through an electronic dashboard. The dashboard was reviewed and discussed monthly at maternity governance meetings, with daily reviews of reported incidents. The outcome of these were also discussed at maternity performance meetings, with any learning shared as part of the weekly safety bulletin.

The service reported there were 8 cases of elective caesarean sections cancelled in August 2025 due to staffing, capacity and flow, and both maternity theatres being occupied. Delays in elective caesarean sections could lead to risks such as increased stress and anxiety for the women and a possible risk of infection. To support the elective caesarean work and increase in caesarean lists, the service had increased staffing within the postnatal ward.

A patient multidisciplinary working group was established to improve flow. The antenatal care ward and induction of labour unit had recently been merged because they were located some distance apart, to support staffing in both areas and to improve the flow for induction of labour women.

We scored the service as 2. The service worked with women and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving women’s lives while protecting their right to live in safety; free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. However, not all staff had completed level 3 safeguarding children training and there were significant concerns raised regarding newborn security.

The service had a clear Maternity Safeguarding Policy and staff were able to explain how they identified adults and children at risk of, or suffering from, significant harm and how to report safeguarding concerns.

The trust had changed the safeguarding children training in January 2025 to incorporate an e-learning training session and a short face-to-face training session. The total compliance for maternity and obstetric staff did not meet the trust compliance of 90% since February 2025, with the most recent compliance being 74.18% for level 3 safeguarding children training.

Reasons for low compliance were due to not all staff completing both parts of the safeguarding training. To improve obstetric compliance, the service was in the process of introducing training passports. This meant that specific training such as safeguarding could be transferred between local trusts.

The newborn security policy was last updated in July 2024, so at the time of the inspection it did not relate to newborn security in the BEACH building. Staff also told us they had not had any recent baby‑abduction or security training since moving to the BEACH. In addition, no baby‑abduction drill had been carried out since the move, even though at the time of the inspection the service had been in the new building for six months. Because of this, the trust could not assure themselves staff fully understood the procedures and protocols needed to prevent a baby abduction.

We were told the newborn abduction drill was not included in the maternity skills and drills training and the last drill took place in the previous unit in 2024. This meant staff were unaware of the processes or procedures they would need to follow in the event of a baby abduction in the new building and staff were reliant on the baby tagging system. However, on review of patient safety incidents, we found there were incidents where babies were not tagged, or the system had not worked.

Following the assessment, the trust provided immediate assurance that the newborn security policy had been updated, and evidence was provided to demonstrate a baby-abduction drill had taken place which had identified further learning and actions. Staff were provided with information and learning on newborn security during ‘hot debriefs’, skills training, team briefings and at huddles.

The maternity unit had security controls such as CCTV, swipe card, and buzzer access. However, when CQC inspectors entered the BEACH building out of hours they were not approached or asked for identification by the security team at the main entrance. On arrival to the triage area at 23.00 the team were let into the unit via the intercom bell without being asked or staff observing who the inspectors were. Staff told us if the bell rang, it could be answered by any area within the maternity unit to let someone in. They also told us that especially at night, they would not always ask for clarification of people at the intercom due to a lack of staffing and being busy.

There was a safeguarding maternity team called Oasis providing consistency and support to vulnerable families. The lead and named midwife for safeguarding provided support to the Oasis team as well as inpatient and outpatient services. This was in line with the trust’s safeguarding guidance.

Due to the complexity of Oasis’ caseload, the team received one to one monthly safeguarding supervision. However, this supervision had reduced due to long term sickness within the Oasis team, with one third of the team reported to be off due to sickness and current midwives covering the immediate needs of the service. The lead midwife for the Oasis team and the named midwife for safeguarding were providing caseload oversight of challenging cases to support the Oasis team during this time.

We scored the service as 2. The service did not always work to understand and manage risks to women and their babies. Staff were not always supported to provide the care to meet women’s needs that was safe and supportive.

Maternity triage is a high-risk area for maternal emergency care. The service used a nationally recognised risk review tool to assess women attending maternity triage. The National Institute for Health and Care Excellence (NICE) guidelines recommend women to be reviewed by a midwife within maternity triage within 30 minutes. However, the trust had set a target for women to be reviewed within 15 minutes of arrival.

Since May 2025, there was an increasing number of women not being triaged within the 15-minute timeframe, and the service was consistently not meeting the trust’s target of 85%. In June 2025 the service was 76% compliant, July 2025 77% compliant and in August 2025 it was 75%. This meant there was a continued risk to the women and their unborn babies by not identifying or addressing potential concerns.

The senior leadership team told us staff had been unable to meet the 15-minute trust target timeframe due to a higher number of women attending maternity triage since the move to the new building, and triage had experienced a high-level of staff sickness.

Midwives working in maternity triage told us they felt unsafe and not able to manage potential risks due to a lack of staff.

The maternity advice line was shared with a neighbouring NHS trust; however, University Hospitals Dorset staffed the maternity advice line. However, this arrangement was currently being reviewed.

The maternity advice line had a call waiting system which queued calls waiting and women were called back if any calls dropped off. Calls were also diverted to maternity triage or the labour ward. During the assessment several staff told us, there were greater pressures for staff when the maternity advice line was not covered, and the calls were transferred to maternity triage or labour ward. Staff shared concerns that there were incidences where junior midwives had answered maternity advice line calls and women had not been given the correct advice.

Midwives working on the maternity advice line received 2 days supernumerary to work with core midwives and they attended a yearly training update.

The staffing rota showed the maternity advice line was unstaffed 11 times in June 2025, 13 times in July 2025 and 31 times in August 2025. The rota sheets reviewed during the assessment showed between 23 September 2025 to 26 September 2025 there were 5 shifts when the maternity telephone triage line was not staffed.

There was no clear process or guidance to support staff in managing women arriving out of hours in advanced labour, and there had been no skills or drills organised to safely manage women in active labour arriving to the building out of hours.

Staff received training in how to identify deteriorating women using tools such as the Modified Early Obstetric Warning Score (MEOWS) and were able to discuss the processes for escalation. The use of MEOWS was to support the detection and response to clinical deterioration.

The MEOWS audit for September 2025 showed 5 out of the 9 areas reviewed within MEOWS met the 90% compliance rate. Following a deep-dive into maternity digital documentation, the service identified that some areas of low compliance were not linked to staff non-compliance, but due to how the information was processed electronically on the digital records.

Sepsis was part of the multidisciplinary PROMPT training which included the deteriorating patient. All staff were trained in early recognition and escalation of sepsis through simulation training and deteriorating patient multidisciplinary sessions. The service reported that sepsis training had been completed as part of the move to the new building.

We reviewed 5 care records for women and there was evidence of evaluation of risk at each contact throughout their care journey, with clear documentation of risk that was acted upon.

The service had seen an improvement in staff completing ‘fresh eyes’ peer reviews, and escalating concerns. The service had met all 10 standards relating to intrapartum cardiotocography (CTG) fetal monitoring.

‘Top tips to CTG monitoring’ posters were observed in the labour ward. Posters suggested staff use a timer or call bell as reminders to complete peer reviews and to escalate when there was not a midwife to complete a peer review.

We scored the service as 2. The service did not always detect and control potential risks in the care environment.

The maternity service moved into the BEACH building at The Royal Bournemouth Hospital on 31 March 2025. The unit was purpose built for maternity services and offered individual rooms for women and additional sleep chairs for partners. Labour ward was situated on the second floor of the building.

We found privacy and dignity was not always maintained within the maternity recovery. Prior to the assessment we received anonymous concerns relating to the privacy and dignity of women who were in the recovery bay following a caesarean section or theatre procedure, due to security cameras being situated directly opposite women in the recovery bays.

There were active cameras within the recovery area during both our onsite inspection visits. The active cameras compromised the privacy and dignity of women going into the recovery bays. Although there was a grey box obscuring the view of the bed space, there were no obvious signs to inform women they were being recorded within the recovery area, and monitors and recorded footage could be viewed by staff with access to the recording equipment and CCTV. We raised concerns with the senior leadership team. Following our assessment, the CCTV monitors were immediately disconnected and removed from the recovery area.

There were no arrangements to provide a dignified space for any situation where women went into active labour in the main entrance. During the assessment we were told staff were aware of the out-of-hours process to follow and screens were available at the entrance of the building. However, when talking to staff, they were not aware of screens and security informed us there were no screens in the entrance, with the nearest privacy screens located within the emergency department.

Staff completed daily checks on specialist equipment, including the post-partum (PPH) and major obstetric haemorrhage (MOH) trolley in labour ward. The emergency resuscitation trolleys were tagged but open in labour ward and triage.

Prior to our assessment staff had raised concerns regarding patient call bells not being heard by staff. However, since the complaints were raised, the service had acted and all staff had a bleep device which alerted them to call bells being used.

The maternity unit was clean, tidy and free of clutter. 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 situated on the labour ward, on a separate corridor to the delivery suite which provided a quiet, private, and sensitive environment for women and their families to privately create memories and spend time away with their baby to grieve.

We scored the service as 2. The service had insufficient numbers of maternity staff to keep women and babies safe from avoidable harm. Staff did not always feel like they received effective support. However, the service had adequate consultant and medical cover.

Maternity services did not have enough sufficiently skilled and experienced midwifery staff to appropriately assess and care for women and mitigate risks in a timely manner. A review of staffing rotas showed significant gaps in service, which meant there was not always the correct skill mix across the maternity unit.

There had not been a formal review of the staffing model (birthrate plus) prior to the move to the new building, the previous birthrate plus had been completed in January 2025.

The service had identified that some staff would not move to the new building and staff turnover would increase. The service reported the turnover of staff from April 2025 was improving. However, there was a high rate of staff sickness, which meant there was insufficient staffing cover which could impact the ability of the unit to offer safe care and treatment to women and babies.

Data reviewed showed in August 2025 there was a 13% sickness rate for core triage midwives. Overall, across maternity triage for both midwives and maternity support workers sickness was 34.6%. Sickness across maternity services in August 2025 was 9.19% with most staff sickness reported to be due to stress and anxiety.

There was an escalation policy and process to attempt to mitigate low staffing levels. An operational Band 7 midwife was scheduled onto the rota daily who had overall responsibility for managing the flow and function of the department. The operational lead used an electronic staffing grid to identify gaps in the service and to move staff accordingly.

Following our assessment the trust reported that 5 staff had returned to work and sickness levels had returned to expected levels. However, the operational manager did not always have the staffing resources to adjust staffing levels daily according to the needs of the service.

There were 2 band 7 midwives rostered per shift. One was supernumerary labour ward co-ordinator and the other was the clinical lead who supported the team clinically. However, multiple staff told us the labour ward co-ordinator was not always supernumerary, and this was supported by red flag data provided by the trust. Red flag data showed from April 2025 to August 2025 there were 7 cases where the labour ward co-ordinator was unable to maintain supernumerary status of not providing one-to-one care in labour and 5 delays reported in providing pain relief.

Staff told and us and we saw during a review of staffing rotas, that it was a daily occurrence where not all shifts on the maternity unit were covered. Staff told us the morale was the lowest it had ever been, and that they did not feel listened to.

Staff reported and we saw examples within rotas where there was inappropriate skill mix, especially within maternity triage and labour ward. There were also incidents where staff were lone working at night on maternity triage. During the assessment we observed insufficient staffing. For example, on maternity triage there were midwife shortages for both the late and night shifts. A band 5, newly qualified midwife was rostered onto the late shift without the support of a band 6 midwife rostered for the night. We also saw an incident reported of staffing concerns around inappropriate skill mix. We reviewed staffing rotas for that day and found there were significant staffing gaps within the rota.

Staff rotas from June 2025 to August 2025 showed there were several gaps in staffing over the 3-month period. For example, the week commencing the 28 August 2025, 4 out of the 7-night shifts on maternity triage were rostered with a midwife. On 2 of those night shifts, there was no maternity support worker rostered. There was no midwife cover for the maternity telephone triage line for 5 out of the 7 nights.

The service had an operational band 7 midwife to manage the flow and function of the unit and to assess staffing and workload. The service had two band 7 midwives rostered per shift. One was supernumerary and has oversight of the maternity unit. The second band 7 is the clinical lead who supported the team clinically.

Staff told us it was common, due to the lack of staffing at night for the co-ordinator not to be supernumerary. This meant there was not always full oversight of the flow around the maternity unit and therefore a potential decline in the quality of care provided.

The head of midwifery (HOM) told us staff working within the Haven midwifery-led birthing unit were expected to care for bereaved women and their families if a bereavement midwife was unavailable. Haven staff expressed their concerns with caring for women who had experienced the loss of a baby while alongside women who had had a happy and positive outcome.

Staff told us, women and their families who had experienced the loss of their baby were not always provided one to one care postnatally.

Providing one-to-one care is important for the emotional and psychological well-being of women and their families experiencing pregnancy loss or the death of a baby. Bereavement suites and specialised bereavement midwives are essential components of maternity services, providing a safe and supportive environment for families to process their grief and make memories with their babies.

Following the inspection, the service demonstrated their commitment to making improvements in this area. The service shared evidence of a detailed and comprehensive improvement plan looking at staffing and that several workstreams had been set up to drive improvement across multiple areas.

There were sufficient numbers of obstetric or anaesthetic staff. All staff reported a positive working relationship between maternity and obstetric staff. The service had a relatively new obstetric clinical lead and a multidisciplinary training lead, and it also had good relationships with the perinatal mental health team.

Staff received training that was relevant to their roles and responsibilities. As well as mandatory training, staff received maternity specific training and learning identified through incidents. They knew when to complete required training and received reminders from their managers. We saw training compliance was monitored through a live database.

The perinatal training programme was provided to all staff who provided obstetric care to women. All staff were compliant in completing the annual fetal surveillance training, which included training on cardiotocograph (CTG) and intermittent auscultation. Auscultation is a method of fetal monitoring during labour that involves listening to the fetal heart with a doppler ultrasound.

There were orientation days facilitated prior to the move by the multidisciplinary teams, including the simulation team, theatre teams, practice development team and obstetric and anaesthetic leads. The service reported 96% of all clinical staff in post at that time attended 1 day of training regarding the new service between January to March 2025.

Staff were compliant in all areas of mandatory and PROMPT training, except midwives had not quite reached the trust’s target of 90%, with a compliance of 87.29% for Saving Babies’ Lives training. Staff were also provided with additional training, such as Unconscious Bias, Outside of Guidance, Home Birth and Pelvic Floor training.

Women felt they were supported by competent staff, involved in decision making, and kept informed about their care. The service had successfully introduced advance clinical practitioners to the service to support maternity teams in obtaining a medical review of women.

We scored the service as 3. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Maternity areas carried out peer review observations of clinical staff. Areas reviewed included before patient contact, before aseptic technique, bare below the elbow or whether hands had been cleaned with soap and water. The aim was to collate 30 peer reviews per month. Any maternity area not reaching above 80% compliance had a discussion with the area matron to agree to an action plan to improve staff compliance.

The service did not report high incidence of maternal or neonatal readmissions due to infection. Maternal and neonatal readmissions for sepsis were reported separately, with maternal cases reviewed by the maternity risk team and the neonatal readmissions reviewed by the readmitted babies work stream. There were 12 readmissions of newborn babies in August 2025, with 16% of those babies readmitted due to possible infection.

The service completed sepsis management in pregnancy audits to improve management of sepsis and to improve the morbidity and mortality rates within the antenatal and postnatal period. The audit demonstrated 100% staff compliance in completing the key elements of the Sepsis Six care bundle.

We scored the service as 3. The service made sure that medicines and treatments were safe and met women’s needs, capacities and preferences. They involved women in planning, including when changes happen.

Staff within maternity triage reported within the last month the service had introduced medicine in triage. There was no access to controlled drugs in triage. Staff told us this meant leaving the unit to obtain medication if needed.

The service had a medicine administration guideline for midwives. Midwives had access to the full list of midwives’ exemptions, so they were clear about administering within their remit.

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.

The service used an electronic system to prescribe and record administration of medicines. There were policies and procedures to support the safe and effective use of medicines.

The pharmacy team supported the service and reviewed medicines prescribed. These checks were recorded in the prescription charts we looked at. Staff completed medicines records accurately and kept them up to date.

The service was part of a collaboration with the local and neonatal maternity systems (LMNS) to provide a perinatal vaccination service for women within the Dorset area. The service had been recognised for delivering a high number of vaccinations to pregnant women in Dorset as part of the LMNS. The vaccination service was found to be one of the highest performing trusts in the country for providing the autumn flu programme to pregnant women.