Dorset County Hospital

On this page

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

Safe

Staff were kind, caring and compassionate. Women using maternity services could access care and treatment when they needed it.

Leaders had taken steps to improve the reporting, monitoring and managing of incidents. There was an improved culture of safety and learning. There was a clear system to investigate incidents and to identify learning.

The service had made improvements within the Day Assessment Unit (DAU) and Triage, and a nationally recognised risk review tool had been introduced since our previous assessment.

The service had a standard operating procedure (SOP) and flow chart for maternity clinical escalation. Staff felt confident they could escalate concerns to leaders, and they felt listened to.

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.

During our review of women’s records we did not see evidence that safeguarding alerts were added to the electronic records. It was not clear how the service assured itself that women and other people using maternity services who were at risk of potential harm were being identified. Following our assessment, feedback was given to the trust and the service implemented immediate action to improve safeguarding checks.

During our assessment we found not all staff fully understood the term ‘virtual model’ for transitional care and there was some confusion around the provision of transitional care services.

Staff checks on emergency equipment were not always completed daily as outlined in trust guidelines/policy. The adult resuscitation trolley was not secure and could easily be tampered with.

At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Good. This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

Women, and their families told us they knew how to complain. They told us they felt safe and reported staff supported them in managing risks.

There was an improved culture of safety and learning, and a clear system was in use to investigate incidents and identify learning. The service used national risk tools, Patient Safety Incident Response Framework (PSIRF) and a Perinatal Quality, Safety Risk (QSR) Framework to review and monitor risk.

The Patient Safety Incident Response Plan (PSIRP) set out how the trust learnt from safety incidents reported by women, and other people using maternity services.

There was a weekly PSIRF maternity and neonatal incident huddle. The huddle was multidisciplinary and reviewed maternity and neonatal incidents as well as identifying learning opportunities. There were no formal meeting minutes taken; however, actions were completed on a live team tracker and updated during the meeting.

Evidence showed the service used actions from local incidents to form part of the maternity specific training. For example, following on from incidents the practice development midwives worked with the incontinence nurses and the pelvic health physiotherapists to provide training on postnatal bladder care. The maternity department purchased a bladder scanner to support the pelvic health programme. All maternity staff were trained to use the bladder scanning equipment to support compliance with the trusts bladder policy.

The service involved the Local Maternity and Neonatal Systems (LMNS) in safety incidents review 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 presented to the LMNS by the maternity service showed how the service had responded to specific incidents, areas for improvement and learning.

There was a formal risk assessment in place for opening and using the second theatre in the event of an obstetric emergency. All incidents where a second theatre was required were reviewed by the Safety Team. Service leaders described how the service was establishing a specific pathway for elective caesareans. A business case for a dedicated second theatre for elective caesarean provision had recently been completed.

The maternity safety team sent out a quality Maternity Safety Newsletter to improve communication and learning from incidents. The newsletter provided information on current maternity audits, learning from incidents, staff reminders and staff suggestions on improving safety within maternity.

Women and their families we spoke with during the assessment were positive about the care they had received. The trust patient experience team collated Friends and Family feedback monthly. Feedback was used to form maternity and neonatal quality improvement projects. There was currently work being carried out to improve postnatal care with a large focus on enhanced recovery for women following a caesarean section. As part of this work, training was provided to maternity support workers on how to provide personal care following a caesarean section.

The maternity service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

Following our previous assessment the service had made improvements within the Day Assessment Unit (DAU) and Triage Unit and had introduced a nationally recognised risk review tool within maternity triage.

Women attended the DAU for both scheduled and unscheduled care.

The service completed monthly audits to determine how long women waited for further assessment and if required, a medical review. Following, the introduction of the nationally recognised risk review tool, midwives told us they had seen a significant improvement within the timeframes of reviewing risk and escalating concerns. Midwives felt there was a better oversight of risk.

The trust set a target of 80% of women to have a medical review within a specific timeframe according to the risk rating tool. Audits showed the service met the target for women being seen hourly and within 4 hours.

Women having a medical review within 15 minutes was below the trust target, but women who were not reviewed within 15 minutes were escalated to the consultant oncall and the maternity co-ordinator. All maternity staff had received training on the nationally recognised tool so they could support in the DAU and triage area if required. However, DAU and triage was covered by core maternity staff for a consistent approach and were more experienced in urgent and non-urgent antenatal care.

Clear guidelines were in place for staff using the risk review tool. Staff compliance of key performance indicators was monitored via an electronic dashboard. Leaders reviewed weekly compliance reports including key performance indicators at the weekly safety summit.

All women were assessed by a midwife using a situation, background, assessment, recommendation (SBAR) tool. The service completed an SBAR audit to evaluate whether the tool was being implemented against current guidance, when maternity staff were handing over care following delivery of baby. The most recent audit took place between March 2025 to May 2025 and showed the service was 96.3% compliant, which met the trust target compliance of 90%.

The service had a standard operating procedure (SOP) for maternity clinical escalation. The SOP identified the key steps to support clinical escalation and there was a flowchart to support decision making. Staff told us they felt confident they could escalate concerns to maternity leaders, and that they would be listened to.

The maternity service worked with the local maternity and neonatal systems (LMNS) to complete quarterly reviews on Saving Babies Lives Care Bundle (SBL). The SBL is a national tool designed to reduce still-birth rates. Between January to March 2025 the service was found to have made sufficient progress in line with locally agreed improvement targets.

There was no specific bay or beds providing transitional care for babies. Transitional care is extra support given to babies who are well enough to be cared for at the bedside with their parents, but who need extra assistance beyond the usual postnatal care.

Service leaders described a virtual model for transitional care, where care was delivered either in the labour ward, post-natal ward or the parent’s room in the special care baby unit. Care for transitional care babies was provided by both the midwifery and neonatal teams and this was reviewed daily, depending on the acuity levels and staffing in both maternity or neonatal services. During our inspection we found not all staff fully understood the term ‘virtual model’ for transitional care and following on from our last assessment there continued to be some confusion around the provision of transitional care services with care mostly being covered by staff from special care baby unit. However, this did not impact on women and baby’s care.

The maternity service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people's lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately. However, the service did not document within women records if there had been system checks for any safeguarding or child protection concerns.

Staff understood and could describe how to protect women from abuse and could give examples which demonstrated their safeguarding understanding. Staff had training on how to recognise and report abuse, and they knew how to apply it.

Safeguarding training compliance was monitored and reported through the trust safeguarding quarterly report which was shared through the safeguarding committee.

Training records showed both midwifery and obstetric staff were 90% compliant with safeguarding level 3 training. All staff who had not completed the training were booked to do so. Staff understood the importance of supporting equality and diversity and ensuring care and treatment was provided in accordance with the Equality Act 2010.

We checked 5 women records, there was no documentation to identify whether a safety log had been completed on their admission. There was no evidence safeguarding alerts were recorded. There was no evidence safeguarding alerts were added to the electronic records.

Following our assessment, feedback was given to the trust and the service implemented immediate action to improve safeguarding checks. GP records for women in and out of area were now checked and a flag was placed in the electronic records to notify staff of any safeguarding concerns. The action was communicated to staff through daily safety briefings, which were given at each shift handover.

Safeguarding training had been revised to provide information on the updated safeguarding system checks and an audit was put in place for ongoing assurance of compliance.

The service had a clear Maternity Safeguarding Policy, which was to be used in conjunction with the trust Safeguarding Children's Policy. Following our assessment, the service was proactive and requested a proposed change to these to add the safeguarding system checks to the policy.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people's needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff used the maternity early obstetric warning score (MEOWS), a nationally recognised tool, to identify women at risk of deterioration.

Since our last assessment the service had developed a standardised audit tool to monitor compliance with staff monitoring vital signs, early warning scores and escalation. An audit of MEOWS observations was undertaken between July to September 2024. Outcomes from the audit highlighted there was some confusion among staff in completing MEOWS, due to multiple electronic records systems.

The service used outcomes from the audit and developed a MEOWS standard operating procedure (SOP), which was currently in draft format, to support staff to competently complete MEOWS.

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.

Our last assessment showed the World Health Organisation (WHO) surgical safety checklist was not checked in a formalised way to reduce the risk of mistakes. At this assessment records demonstrated the WHO checklists were completed but there were discrepancies between the audit processes. The electronic audit did not pull through all information; therefore, the service completed a paper review of documentation. The paper review found there was 99.5% compliance in all areas of the checklist being completed. To ensure consistency in completion of the checklist the service had developed an audit template and completed regular observational WHO checklist audits.

Women were assessed by a trained midwife who used a standardised triage situational, background, assessment and recommendation (SBAR) tool to identify risk. Staff and leaders told us the SBAR tool was used for women during their antenatal, intrapartum and postnatal care.

The service completed a Saving Babies Lives (SBL) quarterly report, which focused on the areas where there was non-compliance and where SBL did not meet the trust target rate. This was to make sure the service focused on improvement with clear actions in place. Quality improvement projects following on from actions were also shared and listed within the report. The report was shared with the LMNS and Integrated Care Board and the service was noted to have made progress in the 6 safety elements within SBL.

The trust maternity dashboard identified all outcomes were within the target range, other than post-partum haemorrhage (PPH) above 1500mls. However, the rate was only very slightly higher than the national target and evidence demonstrated the service completed an improvement project to reduce the number of PPH cases.

During labour, high-risk women were attached to a Cardiotocograph (CTG), which is equipment used to monitor the fetal heart rate and uterine contractions. Fresh eyes' monitoring is national guidance, which recommends the CTG trace is assessed by a second midwife or a doctor regularly, to reduce the risk of error when reading the CTG. Fresh eyes were completed appropriately in all labour notes we reviewed. Staff met all CTG and fresh eyes compliance in all but 1 target.

Data showed the service did not meet the target compliance of 85% for completing fresh eyes hourly, compliance was 73%. Information provided explained the electronic system did not recognise the CTG fresh eye reviews which were outside of the hourly review. Following an audit the service reported the electronic system now collated the data with a 10% buffer either side of 60 minutes. Data was not available at the time of writing to ascertain whether this had improved compliance.

A fetal monitoring lead provided on-ward support to reinforce the importance of timely reviews. There was also the introduction of a buddy system to facilitate peer reviews, and maternity coordinators assigned a midwife per shift to oversee the peer reviews.

The maternity service mostly detected and controlled potential risks in the care environment. Staff did not always make sure equipment, facilities and technology supported the delivery of safe care. However, following notification of risks the service were proactive and put immediate actions in place.

Staff mostly carried out daily checks on emergency equipment. Records showed the neonatal resuscitaire in the delivery suite and the adult resuscitation trolley were not always completed daily. Following feedback, the service revised the method of daily checks with the maternity co-ordinator having oversight to make sure there was daily compliance.

The adult resuscitation trolley was not secure and could easily be tampered with. The service immediately secured the resuscitation trolley with a tamper evident seal.

The trusts' Resuscitation Policy was reviewed because of the findings and the service told us, all trolleys across the trust were sealed to ensure a standardised approach. Work was ongoing to implement the changes to a standard policy, and compliance will be overseen by the Trust Resuscitation Group.

The service provided a full range of maternity services within one maternity area. This included antenatal clinics, day assessment unit, a midwifery led unit, delivery suite,1 obstetric theatre, recovery area and a bereavement suite. The special care baby unit was situated next to the maternity unit, therefore there was quick access if the baby's condition deteriorated or required an urgent transfer.

The service used the obstetric theatre for both elective and emergency operations and procedures. The service used the main theatre when the obstetric theatre was already in use. Staff were now clear and confident in the process of escorting women to main theatres, if required. A second neonatal resuscitaire had been purchased and this was taken down to the main theatre along with the woman or birthing person ready for baby.

There was now greater theatre staffing provision and a standard operating procedure to be followed. There was an experienced theatre technician who led on ensuring all aspects of the maternity theatre ran smoothly and daily checks on theatre equipment took place.

Safe transfer to theatre was added to simulation and practical obstetric multi-disciplinary training (PROMPT) training following the previous assessment and all staff we spoke with during the assessment were confident to explain the process in the of taking women to a second theatre.

The maternity unit was fully secure with a monitored entry and exit system and the service had completed baby abduction drills. The service had suitable facilities to meet the needs of women and families.

Most equipment and store cupboards were visibly clean, tidy, and uncluttered.

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, birthing people and their families. The bereavement area was situated on the labour ward, on a separate corridor.

The maternity service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care that met people’s individual needs.

The service commissioned a recognised national midwifery specific staffing tool to review staffing in November 2024. The tool used reviews intelligence and insights within the unit to be able to ascertain the safe number of midwives and maternity support workers required within the unit. The results showed there had been an increase in the proportion of women with more complex needs delivering their babies at Dorset County Hospital.

Maternity staffing was on the maternity service risk register and was rated as a high risk.

From October 2024 to March 2025 the maternity labour ward coordinator was 100% supernumerary every shift. The labour ward coordinator did not only have oversight of the delivery suite area but of the whole maternity unit. The purpose of the role was to oversee safety. As an experienced midwife they were available to provide advice, support and guidance to clinical staff. They also managed activity and workload through the labour ward.

All specialist midwives were in the process of completing specific training and a competency pack to be able to support labour ward co-ordinators and to ensure there was always supernumerary cover.

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.

The provider mostly assessed and managed the risk of infection.

The environment within the delivery suite rooms looked dated with some staining on the floor in some of the delivery suite rooms. There were inconsistencies regarding the use of ‘I am clean’ stickers and it could not always be determined whether a room had been cleaned.

The service was proactive in completing an immediate review of the use of ‘I am clean’ stickers on the maternity unit. The cleaning policy was reviewed as well as the use of signage to identify recently cleaned equipment and rooms. The service implemented reusable laminated signs to demonstrate a bed area, and all furniture and equipment within the bed space, had been cleaned.

Senior leads confirmed that following the assessment the service improved the signage on the doors of clean equipment cupboards to reinforce the practice of only storing items once cleaned, in accordance with the Trust Cleaning Policy and schedules. An audit was to be carried out to demonstrate compliance and improvement.

There was a standard operating procedure in place for completion of all infection, prevention and control (IPC) audits, so non submission or completion of audits were reviewed.

Evidence showed a discrepancy in the pool cleaning dates, as displayed in the one of the birthing pool rooms. This was reported to staff during the assessment, and we were told the hot water in the pool was not working, and the room was not in use.

The service made sure that medicines and treatments were safe and met people's needs, capacities and preferences. Staff involved people in planning, including when changes happened.

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 a paper-based 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 checked. Staff completed medicines records accurately and kept them up to date.