North Middlesex University 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 people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people'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 has improved to requires improvement. This meant there had been an improvement in the quality of care provided however, there were some aspects of the service that were not always safe.

The service was in breach of legal regulation in relation to the learning culture of the service, mandatory training, staffing, risk assessment, the documentation of risk assessments and the management of infection, prevention and control.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive culture of safety and did not always investigate and report safety events in a timely manner. However, the service did learn from incidents.

Midwifery staff received and kept up to date with their maternity specific mandatory training. The mandatory training was comprehensive and met the needs of women and staff.

Maternity specific mandatory training included but was not limited to practical obstetric multidisciplinary training (PROMPT), fetal monitoring, saving babies lives bundle training, infant feeding, maternity skills, neonatal life support and maternal basic life support. Midwifery staff exceeded the trust target of 90% in all maternity mandatory training. This was an improvement since the last inspection.

Medical staff received but did not keep up to date with their mandatory training. The compliance rate was 98% for fetal monitoring, 73% for PROMPT, 51% for saving babies lives bundle training, 72% for neonatal life support and 86% for maternal basic life support. Medical staff consistently did not meet the trust target of 90% in their mandatory training, except fetal monitoring. GP trainees were highlighted as the medical group with the lowest compliance rate. This meant that we could not be assured that medical staff had enough training to keep women and babies safe from avoidable harm and was a continued breach since our last inspection.

The practice development team monitored midwifery and medical mandatory training and alerted the matrons of clinical areas and staff when they needed to update their training. To improve medical staff training compliance, the practice development midwives have started booking medical staff training 2 months before the training was due to expire. They also added the training sessions directly into doctors' calendars and actively engaged with medical staff to ensure attendance.

Staff we spoke with knew what incidents to report, how to report them and felt comfortable doing so. Staff also reported that they received feedback from incidents reported.

Managers reported that they reviewed incidents submitted by staff via an incident reporting system regularly. We reviewed incidents submitted by staff from July to December 2024 and noted that incidents were not always graded appropriately. We noted that incidents of major obstetric haemorrhage and third-degree tears were graded as low harm. However, the trust explained that this grading was a post-investigation grading and not the initial classification.

The service reviewed incidents graded moderate harm or above at a weekly incident risk group (IRG) meeting. Meeting minutes submitted by the trust showed that the meetings were well attended by varying members of the multidisciplinary team. Incidents were discussed in detail and the group determined the appropriate learning response and whether further investigation was required.

Managers investigated incidents and involved women and birthing people, and their families in these investigations. Data supplied showed that each incident had a handler who updated the actions taken and outcomes. However, incidents were not always investigated and closed in a timely manner. Data provided from the trust showed that the service had 49 open incidents, 21 of which had been opened for over 60 days. It was noted however, that some of the incidents rated as severe harm and death were open due to external investigations being carried out by the Maternity and Newborn Safety Investigations (MNSI) after being referred by the trust. The remaining incidents rated moderate, low and no harm were delayed for varying reasons, these included the incident being overdue a local investigation by a consultant, a patient safety incident investigation being triggered and delayed and referral to MNSI.

Lessons were learned from safety incidents and complaints, resulting in changes that improve care for others. An example of learning from incidents and complaints was the introduction of a protected breastfeeding midwife on the maternity ward 2 times a week, providing dedicated 1 to 1 and group breastfeeding sessions. This was introduced in response to high rates of neonatal readmission for weight loss and complaints from women and birthing people regarding a lack of breastfeeding support. Another example was the introduction of a tool to improve interprofessional telephone handovers between midwives and neonatal doctors. This was introduced to reduce delay and ensure the appropriate members of the team attended emergencies.

We observed clinical governance boards in all the clinical areas which highlighted the top three complaints, risks and incidents for the month. The board also identified learning from incidents, feedback from staff and training compliance. Staff also reported that the risk team send out message of the week via email with information on risks and incidents within the service.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. Staff did not always manage or monitor people's safety through documentation.

Staff did not always complete risk assessments for women and birthing people on admission in a timely manner. Most women attending the maternity unit were admitted through maternity triage. The maternity triage service used the Birmingham Symptom-Specific Obstetric Triage System (BSOTS) to assess women on arrival. This was an improvement since the last inspection. BSOTS is a system used to assess women presenting with pregnancy related concerns to be seen or prioritised based on their clinical need. Prioritisation was undertaken using a red, amber, green (RAG) rating system and then recorded on a paper documentation sheet. According to BSOTS women should be seen by a midwife within 15 minutes of arrival and prioritised as either red, orange, yellow or green. Each colour identified how soon women and birthing people should be reviewed by a doctor or midwife as required. A red rating required immediate transfer to labour ward, orange required a review within 15 minutes, yellow required a review within 1 hour and green required a review within 4 hours.

Data supplied by the trust showed that compliance with 15-minute initial midwife review was 85% in October, 87% in November and 84% in December 2024. This was slightly below the trust target of 90%. Compliance for women being reviewed by doctors in line with their RAG rating was 71% in December 2024 which did not meet the trust target of 90%. Data for October and November 2024 was not supplied.

Documentation was not always completed appropriately within triage. On inspection, it was identified that staff were not always completing the triage whiteboard and logbook. The triage white board was a part of the service's BSOTS system and a visual aid to all staff on triage. Information on the board included a patient identifier (initials), gestation, location of patient, arrival time, triage time, RAG rating, admission reason, timings for doctor review, plan and outcome. The board should have been updated contemporaneously however, this was not the case which meant that it did not always reflect the activity on the unit. This could potentially affect oversight of activity and acuity in relation to appropriate staffing. Triage did however have a daily huddle at 10:30am and 6pm which improved oversight of acuity and escalation.

The triage logbook also had gaps in documentation, staff were meant to document time of arrival, initial time seen by a midwife, time of referral to a doctor or midwife (as appropriate), time seen and discharge/ transfer time. On day 1 of inspection, the compliance of documentation of; time of arrival was 100%, initial time seen by midwife was 69%, time of referral was 52%, time seen was 42% and discharge/ transfer time was 81%. These gaps in documentation could affect accuracy of future audits of timing and efficiency within triage. However, each patient's BSOTS form was kept up to date which meant staff could still manually pull data on some of the standards audited. The service also had an action plan in place to improve documentation, review times and to manage the volume of women seen in triage, this included but was not limited to the introduction of an electronic patient record system and dedicated medical staffing.

The service had a dedicated telephone triage midwife 6 days a week, from 10am to 6pm which was an improvement since the last inspection. However, this service was not provided 24 hours a day, 7 days a week in line with guidance set out by the Royal College of Obstetrician and Gynaecologists (RCOG): Maternity Triage, Good Practice Paper. The service did, however, have mitigations in place for out of hours which included redirecting the phone line to another area within maternity with the least acuity, which was usually labour ward or the birth centre. All midwives had training on BSOTS, the service also reported that they were actively recruiting for another band 7 telephone triage midwife.

Women and birthing people's notes were not always comprehensive, and staff reported that they could not always access them easily due to the mixture of paper and electronic notes. The service reported that they had procured an electronic patient record system and planned to introduce the system within maternity in April 2025 to help alleviate this issue. However, records were being stored securely.

During the inspection, we noted that risk assessments, such as carbon monoxide monitoring and risk factor identification, were not always documented as being completed, which meant we could not be assured that women were being risk assessed, and issues were being escalated appropriately.

During labour, high-risk women and birthing people were attached to a Cardiotocograph (CTG), which is an equipment used to monitor the fetal heart rate and uterine contractions. According to NICE guidelines NG229, women on a CTG during labour should have an hourly fresh eyes review of the reading. Hourly fresh eyes require two clinicians to review the CTG trace during the intrapartum period to ensure the baby is safe to continue with labour. The fresh eyes stickers were completed appropriately in all the labour notes we reviewed; however, they were not always completed hourly. For example, one set of notes we reviewed had 5 fresh eyes missing. The service carried out a monthly audit of CTG documentation, compliance in October was 93%, November was 97% and December 2024 was 93% which exceeded the trust target of 90%.

The labour ward did not have centralised cardiotocograph (CTG) monitoring system in place due to infrastructure issues that the service was currently working on. Centralised CTG monitoring would allow staff to have access to CTG monitoring in all labour ward rooms to enhance oversight from the obstetric team. Leaders reported that the introduction of an EPR system would help with the implementation of central monitoring and that this was on the risk register.

Shift changes and handovers did not always include all necessary key information to keep women and babies safe. A handover we observed on the maternity ward did not begin with introductions, did not follow a structured approach such as the situation, background, assessment, recommendation (SBAR) tool, was not comprehensive and had multiple disruptions, which was not in line with The Royal College of Surgeons of England: Safe Handover guidance. This meant we could not always be assured that all staff had the necessary information to keep women and babies safe. However, safety huddles that we observed were structured, comprehensive and were held in a room with no interruptions in line with national guidance.

Leaders monitored waiting times and made sure women, and birthing people could access emergency services when needed and received treatment. Staff on triage reported that they were able to transfer women who needed immediate attention or were admitted for an induction of labour easily once the labour ward coordinator was contacted.

Staff followed up-to-date policies and processes that align with other key partners involved in patient care. All the policies reviewed during the inspection were easily accessible to staff via the intranet, comprehensive and up to date, this was an improvement from the last inspection.

The service remained fully operational and did not close to the public at any point between the months of January 2024 and January 2025.

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. However, the safeguarding team had limited staff in comparison to the needs of the local population and medical staff did not always complete training specific for their role.

Midwifery and medical staff received training specific for their role on how to recognise and report abuse. The service provided midwifery and medical staff with level 3 safeguarding training which included but was not limited to training on domestic abuse, mental health, substance misuse and female genital mutilation (FGM). Training was facilitated via e-learning which was implemented due to COVID-19, but the service informed us that they are planning to bring back face-to-face training. At the time of inspection, the compliance rate for midwifery staff was 97% which exceeded the trust target of 90%. However, medical staff did not always complete the training, the compliance rate for junior medical staff was 60% which was significantly below the trust target. Data for consultants were not submitted which meant we were not assured that all medical staff had received appropriate training in line with the Intercollegiate guidelines on safeguarding and knew how to recognise and report abuse. This was a continued breach since our last inspection.

The safeguarding team was made up of a named safeguarding midwife and a band 7 safeguarding midwife who were both involved in triaging safeguarding referrals, attending ward rounds on the unit, attending case conferences and coordinating training. The local population served had high levels of deprivation which resulted in a large number of safeguarding referrals at booking and throughout pregnancy which was managed by a limited team. Between December 2023 and December 2024, the safeguarding team received 441 referrals at booking alone. The service reported that they are actively recruiting another band 7 midwife to help make the workload more manageable.

Staff reported that they knew how to make a safeguarding referral and who to inform if they had concerns. Staff could give examples of how to protect women from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff also knew how to identify adults and children at risk of, or suffering, significant harm and knew where to document and access this information. Staff worked with other agencies such as social services and the independent domestic violence advocates (IDVAs) to protect women and birthing people and babies.

The service had relevant safeguarding policies in place which was comprehensive and in date. Staff followed the baby abduction policy and undertook regular baby abduction drills. The maternity ward had security measures in place to prevent baby abduction, this included a baby tagging system, which involves a tag placed on each baby's leg that triggers a lockdown and alarm system if a baby goes near the entrance. However, during the inspection, the tagging system was not in use due to a delay in the ordering of more baby tags. The service had security at the entrance of the ward 24 hours a day, 7 days a week as an extra mitigation to ensure the safety of babies and prevent baby abduction.

Staff provided care to meet people’s needs that was supportive and enabled people to do the things that mattered to them.

Staff used a nationally recognised tool to identify women at risk of deterioration, the service used maternity early obstetric warning score (MEOWS) chart to document women’s observations. Audit data provided by the trust showed compliance with the trust target of 90% in the use of MEOWS charts and escalation between the months of November 2024 and January 2025. However, during the inspection we noted that information such as the date and the score were not always documented appropriately. The service had an action plan in place to improve compliance of the use of MEOWS charts.

Staff did however complete venous thromboembolism (VTE) scoring in the notes of women and birthing people we reviewed onsite.

Staff completed newborn risk assessments when babies were born using recognised tools and reviewed this regularly. The service used a keeping babies and mothers together (KMBT) booklet to document babies risks and observations. During the inspection, booklets we reviewed were completed appropriately. Audit data provided by the trust showed compliance with the trust target of 90% in the use of the KMBT booklet between the months of November 2024 and February 2025.

Theatre staff completed the World Health Organisation (WHO) 5 steps to safer surgery checklist prior to starting surgical procedures in all the women and birthing people’s notes we reviewed. The WHO checklist is a set of priority checks to ensure patient safety before, during and after a surgical procedure. Data submitted by the trust showed 100% compliance in completion of the WHO checklist between October and December 2024.

The service had access to translation services, such as interpreters and a healthcare translation app, however they were not always used when necessary. The app helped patients and staff overcome communication issues with instant access to 1000s of clinically interpreted interactions in over 50 languages and formats including British Sign Language (BSL). Data submitted by the trust showed a 25% usage rate of interpreters for all booking appointments between November 2024 and January 2025 and an increase in the use of the healthcare translation app from June to November 2024. However, during the inspection, we observed a missed opportunity for an interpreter to be used by a midwife on the birth centre for a woman who spoke limited English.

Staff gave women and those close to them help, emotional support and advice when they needed it. Staff also made sure women living with mental health illnesses, learning disabilities and dementia, received the necessary care to meet all their needs. The service had 24-hour access to mental health liaison and specialist mental health support. The service also had a dedicated mental health team of midwives for women and birthing people with additional mental health needs.

The service had relevant information promoting healthy lifestyles and support on wards which were also available in other languages. We observed notice boards on the maternity wards with information on reduced fetal movements in pregnancy, stop smoking advisors, getting access to free vitamins, free postnatal fitness classes and safe sleeping with babies etc.

Women and birthing people we spoke with during the inspection reported that midwives and doctors were very accommodating to their needs and supported them to make informed decisions about their care. Overall women and birthing people felt involved in decisions about their care and felt positive about the care they received.

The service detected and controlled potential risks in the care environment. However, staff did not always make sure equipment, facilities and technology supported the delivery of safe care.

The design of the environment followed national guidance. The maternity services at the hospital consisted of an antenatal clinic, maternity day unit, triage, birth centre, labour ward and maternity ward. The unit was open 24-hours a day, 7 days a week and was fully secure with an entry and exit system monitored by ward clerks from 8am to 8pm and maternity staff overnight in all areas. The maternity ward also had security presence 24 hours a day, 7 days a week. During the inspection, we observed entry to all areas within the service being operated appropriately by staff and staff questioning inspectors and visitors to prevent tail gating and unauthorised visitors.

The service had carried out ligature risk assessments of the environment in line with NHS England National Patient Safety Alert/2020/001/NHSPS. We did not observe any ligature risks onsite.

The service had enough suitable equipment to help them to safely care for women and birthing people and babies. We observed and staff reported an improvement in the amount of equipment available, this included but was not limited to cardiotocographs (CTG), Sonicaids and observation machines. This was an improvement since the last inspection.

The service had suitable facilities, to meet the needs of women and birthing people and their families. Birthing partners were supported to attend the birth and provide support to women and birthing people in all areas within the service. The service had bereavement facilities in the event of fetal loss. The bereavement room was soundproofed and had adequate facilities to meet the needs of families. However, to reach this designated room the woman, birthing person and family had to attend the main labour ward door and walk through labour ward to the bereavement room. This was not in line with the national bereavement pathway recommendations and the Stillbirth and Neonatal Death Support's (SANDS) position statement. This was not an improvement since the last inspection.

Staff mostly carried out daily checks on emergency equipment. During the inspection we observed that neonatal resuscitaires checks were completed daily within the labour room checklists and there were no gaps, which was an improvement since the last inspection. During the inspection, the adult resuscitaires were checked daily in all clinical areas except the maternity day unit (MDU) where we noted minimal gaps in the daily checks. We also noted expired and missing medical consumable equipment on the adult resuscitaires on labour ward and birth centre. This was exposing women and birthing people to the risk of harm. A size 9 endotracheal tube and 2 size 12 suction catheters were missing and another suction catheter expired in November 2024. This was escalated to leaders and rectified immediately.

The service submitted data from an audit of safety equipment checks between October and December 2024. Compliance for adult resuscitaires was 96%, neonatal resuscitaires was 98% and emergency trolleys was 99% which was in line with what we found on inspection. It was unclear what the trust target was, however, the service had recommendations and action plan to help achieve a 100% compliance rate. This included but was not limited to regular audits, spot checks and reminders during safety huddles.

We also noted gaps in the daily checks of the birthing pool on labour ward. We observed 4 gaps in November 2024, 2 gaps in December 2024 and 5 gaps in January 2025.

Women could reach call bells, and we observed staff responding quickly when called on the maternity wards. Staff disposed of clinical waste safely, we observed sharps bins being filled within a safe limit and clinical waste and domestic waste being segregated and labelled correctly.

The service did not always monitor and report staffing concerns in line with national guidance. However, the service made sure that staffing levels met planned numbers and staff worked together well to provide safe care that met people's individual needs.

The service had enough midwifery and medical staff to keep women and babies safe, during the inspection the number of midwives, maternity support workers and medical staff matched the planned numbers. The service had a good skill mix of medical staff on each shift and reviewed this regularly. The service reported that they always had a consultant on call during evenings and weekends. The service had an obstetric and anaesthetic consultant available on call for emergency cover.

The service used the operational pressures escalation level (OPEL) framework to measure operational pressures. The OPEL framework calculated triggers that affect operational performance during a shift and produced a level for the service. OPEL 1 identified low risk, OPEL 2 identified medium risk, OPEL 3 identified high risk and OPEL 4 identified very high risk. The service provided data that showed they had acquired and planned to start using the birth rate plus acuity tool which is a midwifery- specific acuity tool to improve monitoring of staffing, acuity and capacity.

The service had a safety huddle in all areas, the safety huddle on labour ward was co-ordinated by the labour ward co-ordinator and attended by staff from the obstetrics, anaesthetics, quality and safety, neonatal teams and the shift bleep holder. We observed staffing and the OPEL status of the whole unit being discussed at this daily safety huddle. Staff reported that staff shortages were escalated to the bleep holder who had oversight of the staffing, acuity, and capacity and would adjust staffing levels daily according to the needs of women and birthing people. Staff also reported an improvement in staffing since the last inspection.

The service had a full staffing acuity exercise review by birth rate plus in July 2024. This showed that maternity services required an uplift of staff which was presented to the maternity board. It was unclear whether the uplift was approved however, staff reported ongoing recruitment. The service had reducing midwifery vacancy rates, the vacancy rate had reduced from 5.1% in November 2024 to 3.7% in December 2024 which was an improvement since the last inspection. The service had a retention midwife in post to manage staff turnover rates. The medical vacancy rate was 13.1% which was due to recent retirement, reduction in working hours, maternity leave and junior doctors working less than full time hours however, the service was currently recruiting into these vacancies and used locum staff. It was unclear what the trust target was for vacancy rates.

The service only submitted shift fill rate data for June 2024 which showed an average fill rate of 88% on day shifts and 97% on night shifts for midwifery staff against a trust target of 90%. The service used bank and agency midwifery staff and locum medical staff to cover staff shortages. Data for June 2024 showed an average fill rate of 20% fill rate for bank staff and a 2% fill rate of agency staff across the unit. However, the service reported that they used regular agency midwives who were familiar with the service and made sure all bank, agency and locum staff had a full induction and understood the service. Due to recent data not being submitted it is unclear what the current fill rates are or whether the service is meeting the trust target.

The sickness rate for midwifery staff was 4.24% and 0.36% for medical staff in November 2024. It was unclear if this had improved as the service did not provide data for December 2024 or January 2025.

The service monitored maternity `red flag' staffing incidents in line with National Institute for Health and Care Excellence (NICE) guideline 4 `Safe midwifery staffing for maternity settings. A midwifery `red flag' event is a warning sign that something may be wrong with midwifery staffing. The service provided data that identified 8 red flag events in the last 6 months. However, it appears that there is evidence of underreporting as an incident of a labour ward coordinator not maintaining supernumerary for approximately 3 hours was not identified as a red flag. The data also did not appear to include incidents of delayed care from triage. In addition, red flag data submitted to the trust board was not broken down to show the number of incidents for each red flag event. This meant we could not be assured that the board had oversight of the key areas of staffing concerns identified by red flag data.

Managers supported staff to develop through yearly, constructive appraisals of their work. Data from the service showed that both midwifery and medical staff appraisal compliance rates met the trust target of 90%, this was an improvement since the last inspection.

The service did not always meet control of substances hazardous to health (COSHH) standards or managed the risk of infection in relation to maintenance of furnishing. However, staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Ward areas were clean however, the furnishings were not always well-maintained. Staff cleaned equipment after patient contact and labelled equipment with green `I am clean' stickers to show when it was last cleaned however, we observed chairs in the triage waiting room that were cracked and torn.

Daily cleaning was completed by domestic staff and maternity support workers however, they were unable to show us a daily up-to-date cleaning record to demonstrate that all areas were cleaned regularly. The service however, performed regular cleaning spot check audits throughout the month to check all areas in the unit were clean and fit for purpose. The average overall score for all areas from November 2024 to January 2025 was 96%, against a trust target of 95%.

Staff had clear roles and responsibilities around infection prevention and control. We observed staff following infection control principles, including the use of personal protective equipment (PPE) and hand hygiene. The trust provided hand hygiene audit data from November 2024 to January 2025 and results showed 100% compliance in all areas. This was an improvement since the last inspection.

The service did not meet control of substances hazardous to health (COSHH) standards. During the inspection, domestic staff reported that cleaning detergent was kept in their personal locked cleaning trolleys however, we observed cleaning detergent in an unlocked area on the birth centre that could be accessed by women and birthing people and their families. This was escalated to leaders and removed immediately.

Women who were booked for elective caesarean sections were screened for methicillin- resistant staphylococcus aureus (MRSA) during their pre-operative assessment appointment. MRSA is a type of bacteria that is resistant to many antibiotics and can cause life threatening infections as a result.

The service made sure that there were systems and processes in place to manage medicines and treatments safely.

Staff mostly followed systems and processes to prescribe and administer medicines safely. Medicines were prescribed on paper charts. Medicine records we reviewed showed that allergies and weights were always documented to ensure medicines were prescribed safely and, medicine charts were fully completed by staff when administering medicines.

Medication was stored securely, we did observe one medicine fridge left unlocked however, the fridge was in a clinical room that had swipe card access. Ambient, fridge and freezer temperatures where medicines were stored were mostly monitored and staff, we spoke with understood when to escalate. However, on the maternity ward and triage we saw there were some gaps in the daily checks and documentation of the ambient temperatures.

Controlled drugs (medicines requiring additional security measures due to their potential for misuse and diversion) were stored securely and checked daily to ensure their balances were correct. However, we identified that improvements in documentation in the CD book were required as the current documentation system could lead to potential errors when checking, particularly for new staff not familiar with the system. This was escalated to leaders, and actions were taken to mitigate the concerns raised. Non-CD medication was stored securely.

Staff learned from safety alerts and incidents to improve practice. Leaders were able to give us examples of practice changes as a result of incidents, this included the introduction of pre-made insulin syringes by pharmacy.