Luton and Dunstable 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. This means we looked for evidence that people were protected from abuse and avoidable harm. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

At our last inspection we rated this key question inadequate. At this assessment the rating has remained inadequate. This meant there were still aspects of the service that were not safe.

At the previous inspection the service was in breach of regulations relating to safe staffing, mandatory training compliance, equipment checks and clinical waste management. At this assessment, the service was found to be in breach of regulation relating to the provision of safe care and treatment, relating to staffing, mandatory training and appraisal compliance, incidents and complaint management and duty of candour.

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.

The service did not have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Between December 2024 and June 2025, 1609, incidents were reported through the trust’s incident reporting system. Each incident was reviewed at an incident review meeting to determine whether a full investigation was required or if a local review would sufficiently identify themes and learning opportunities.

At the time of our assessment, the service had 1536 incidents open. Of these, 210 were graded as causing moderate harm. Additionaly, 1,131 incidents were either overdue for investigation or closure, or had unresolved recommendations; some dating back to February 2023. This significantly exceeded the trust’s target of closing incidents within 60 days and showed no improvement since our previous inspection. Data received following our inspection showed that of 21 June 2025, there were 873 incidents still open and overdue over 60 days, with 24% of these having occurred in 2024. However, an ICB Maternity Improvement Board paper review dated 08 August 2025 stated there were 1,274 overdue maternity incidents at the service as of 30 June 2025. Staff told us and we received a whistleblowing concern around persistent backlogs of a significant number of open action plans in relation to internal and external maternity incident investigations. This demonstrated a lack of improvement since our previous inspection.

Staff reported the backlog of incidents were due to lack of multidisciplinary team (MDT) capacity, an increase in moderate and severe incidents and a high number of open action plans. For example, we identified a 14-month delay in the completion of an intrauterine death investigation. This was not in line with the trust’s 6 month target. We reviewed a fatal neonatal death incident from February 2024. Although the investigation was complete, actions remained outstanding; particularly those relating to growth scan capacity within the maternity service.

The delays in incident investigations and overdue action plans risk leaving underlying issues unresolved, increased the potential for avoidable harm to women and babies and compromising patient safety.

We escalated our concerns to senior staff. In response, the trust’s governance team reported work was ongoing to close all outstanding incidents. This involved midwifery staff picking up bank shifts and doctors being allocated extra time to review incidents. Incident management was part of the maternity improvement plan, and the trust had put in additional clinical resources and governance meetings to clear the incident backlog. However, we found the service did not ensure there was a robust system in place to ensure lessons were learned and some of the improvement actions in place were still in their infancy. This meant we were not assured that the actions taken to improve learning from incidents were effective.

Not all midwifery and obstetric staff were clear about their roles and responsibilities in relation to incident reporting. Some staff reported they had not received training on how to use the incident reporting management system and were unsure about which types of incidents should be reported; for instance, delays in transfers and gaps in staffing levels. This raised concerns that gaps in staff knowledge could lead to under reporting of incidents, a lack of understanding of appropriate follow up actions, and missed opportunities to learn from incidents and safeguard women and babies from harm.

The service confirmed the risk of under-reporting through checks it began in May 2025. This work identified incidents recorded in the electronic patient information system that had not been reported through the incident reporting system contrary to trust policy. For example, on 10 June 2025, triangulation work (data checks) using the electronic patient information system identified 18 Category 1 caesarean sections that had been reported retrospectively. The following day, during a governance meeting we observed on 11 June, least an additional 10 Category 1 caesarean sections were similarly reported retrospectively. As a result, a total of 28 retrospective reports relating to category 1 caesarean sections were identified during the assessment period.

Although the data checks may have helped reduce the risk of missed incidents in the short term, the underlying issue of staff awareness and understanding of reporting procedures had not been addressed. Additionally, incidents that occurred before May 2025, had not been reported, investigated or identified through the temporary triangulation work. Therefore, we were not assured that systems in place were effective enough to support sustained improvement.

Senior staff told us that following incidents investigation, themes and learning were shared through monthly newsletters and team meetings. We also observed that incidents and complaints were being discussed during governance meetings, as reflected in the minutes we reviewed. However, learning from incidents was not consistently identified or shared. Staff, including specialist midwives we spoke with, were unable to articulate any support, learning or improvement to the service following recent serious incidents. There was limited evidence that changes had been made as a result of feedback and incident investigations. It was unclear what improvements had been made between internal and external incidents investigations undertaken in the last 12 months to prevent similar incidents occurring again. It was unclear if the service knew what their incident trends and themes were, considering the significant backlogs of incidents. Staff acknowledged that learning from incidents was not always shared. Staff did not always receive feedback and learning from investigation of incidents, both internal and external to the service. This had not improved since our last inspection.

Although staff demonstrated an understanding of the duty of candour, the service was not always open and transparent. There were delays in providing patients and their families with a full explanation when things went wrong. Evidence provided by the trust showed poor compliance with duty of candour, which was also recorded on their risk register. The trust’s duty of candour policy required staff to complete duty of candour stage 1 and stage 2 notifications within 10 working days of an incident, and stage 3 within 10 days following executive sign-off of the incident investigation. As of 21 June 2025, compliance rates were 84% for stage 1, 82% for stage 2 and 55% for stage 3, against the trust’s target of 100%. We found processes in place to support compliance with duty of candour were ineffective which did not promote a culture of transparency, trust or accountability. Senior managers told us that a duty of candour task and finish group had been established to improve compliance.

At the time of our inspection, the service had 35 open complaints, of which 25 were overdue an investigation and had exceeded the trust’s target of completing investigations within 45 days. Senior staff told us that 8 of the 25 complaints had been investigated and were awaiting approval from the clinical service leads. Delays in complaint investigations can contribute to increased patient dissatisfaction, hinder timely improvements to patient care, and increase the risk of harm to both women and staff, as underlying contributory factors may remain unidentified or unresolved.

The service did not establish and maintain safe systems of care. They did not always manage or monitor people’s safety.

Staff completed risk assessments for women on arrival, using a recognised tool, and reviewed this regularly. However, there were delays in the review of women in maternity triage by midwives and doctors. Staff used an evidence-based, standardised risk assessment tool for maternity triage. Leaders monitored waiting times to ensure women could access emergency services when needed and received treatment within agreed timeframes. According to the triage policy, women should be seen by a midwife within 15 minutes of arrival and prioritised according to clinical presentation using the triage tool.

Triage audit data from May 2024 to April 2025, showed that midwives assessed 80% of women within 15 minutes of arrival against the 90% target. Additionally, 76% of women were reviewed by doctor within the expected time frame, and 94.3% of women had appropriate referral and follow-up, exceeding the trust’s target of 90%.

Staff told us that the medical cover in triage had improved since our last inspection, where triage was covered by the medical on-call team. In 2024, a twilight shift was introduced 5 days a week. The service now had dedicated medical cover between 12pm and 9pm, 7 days a week. Staff reported this helped improve escalation and the review of women by medical staff in triage.

The service operated a telephone triage service that was staffed by a midwife 24 hours a day, 7 days a week, and provided continuous access to the unit for women with concerns. However, evidence provided by the trust showed that call waiting times and abandonment rates for the triage line were not being monitored. Between 01 January and 18 June 2025, the triage telephone assessment line received 14065 calls, with an average call duration was 4 minutes and 38 seconds. However, the audit did not capture data on call waiting times or abandoned calls. Therefore, there was a lack of understanding and oversight of delays or missed calls experienced by women calling the triage line to be assessed, supported and prioritised by a suitably qualified member of staff. This gap in oversight could lead to delays in accessing appropriate care and support and could increase the potential risk of harm to women and their babies.

The service did not consistently provide continuity of care for women. Staff reported delays in both induction of labour (IOL) and elective caesarean sections and expressed concerns that the booking process was unsafe and in need of improvement. Induction of labour is a medical procedure used to start labour artificially. The procedure usually begins on the maternity ward before women are transferred to the labour ward for the next stage of induction or delivery of their baby.

Between November 2024 and April 2025, the service recorded 362 red flag events, of which 278 related to delayed or cancelled time critical activity and 50 events involving delays between admission for induction and the start of the process. It was unclear whether any actions were being taken to address these issues, raising concern about potential risks to timely care and patient safety.

Staff did not consistently follow current policies and procedures. At the time of our assessment, we identified 12 hospital specific policies and guidelines, along with 15 cross-site policies and guidelines that were out of date. These included but were not limited to critical areas such as management of abduction or suspected abduction of an infant or baby, sepsis management, management of post-partum haemorrhage, and care for babies born before arrival and unplanned home births. We also found 17 out of date standard operating procedures (SOPs) including those related to swab instruments and swab counts within the service. This reflected no improvement had been made since our previous inspection. We escalated this issue to the trust, which explained the delays in reviewing the guidelines were due to limited capacity among multidisciplinary staff, caused by clinical workload pressures. Senior staff told us that plans were in place to address the out-of-date guidelines. At our follow up visit, we noted the trust had made some progress in updating some guidelines and had developed a plan to update the remaining outdated documents.

The day assessment unit was open 5 days a week and the service had plans to extend the service provision to 7 days a week from 1 July 2025 to meet women’s needs and enhance their experience.

Staff reported timely access to patients records, which were paper notes, diagnostic results and the electronic medicines system.

The service’s referral and admission procedures ensured that all essential information about each woman was received, allowing them to assess whether their needs could safely be met.

Staff involved all the necessary healthcare and social care services to ensure continuity of safe care, both within the service and post-discharge.

Staff did not always complete training on how to recognise and report abuse or follow up to date trust guidance. However, the service worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that.

Not all staff had completed safeguarding training relevant to their specific role. However, staff we spoke with were aware of how to raise safeguarding concerns and did so appropriately when required.

Data provided by the trust showed poor compliance with safeguarding training at level 3. As of 20 June 2025, 48% of doctors and 57.1% of midwives had completed safeguarding adults level 3 training. In the same period, 63.3% of doctors, 89.4% of midwives and 89% of maternity support workers had completed the safeguarding children level 3 training. This was below the trust’s target of 90%. As of 10 June, staff achieved 84% compliance in the safeguarding adults’ level 2 training. These shortfalls in training compliance posed a potential risk of harm to women and their babies. The trust told us they were reviewing staff compliance with level 3 training and were in the process of scheduling additional internal and external training sessions for medical staff to improve compliance.

The maternity wards had security measures in place to prevent baby abduction which included a baby tagging system, controlled access to all areas and ward clerk presence. However, staff did not follow the baby abduction policy and undertake regular baby abduction drills. The last drill took place in December 2023 and all actions in the from the action plan had been completed. The service was planning the next abduction drill between June and October 2025. During our follow-up visit in July 2025, we also noted that the baby abduction policy was out of date since June 2025.

The service’s maternity safeguarding standard operating procedure was out of date, which raised concerns about the reliability and accuracy of its content. However, staff knew how to identify and protect adults and children at risk of, or experiencing, significant harm, including those with protected characteristics under the Equality Act. This included working in partnership with other agencies.

The service had a named safeguarding midwife for maternity, who played a key role in overseeing safeguarding cases, supporting staff and facilitating training sessions. Staff told us that the safeguarding team were supportive and visible.

Staff followed appropriate procedures to ensure the safety of children visiting the service.

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.

Staff did not always complete risk assessments for each woman on admission. The 2024 maternity record audit showed an overall compliance rate of 78% across all standards audited: however, their compliance with vitamin K documentation was significantly low at 47%, against a 90% target. The service had not yet completed a follow-up audit due to staffing constraints and limited resourcing in the governance team. The service had plans to schedule the audit later in the year.

Women’s notes were comprehensive, and all staff could access them easily. Records were stored appropriately but not always securely. We observed several loose papers within the intrapartum and postnatal notes. We reviewed 10 paper records and found they were generally clear and complete. However, 1 record had some gaps in completion of cardiotocograph (CTG) and Situation Background Assessment and Recommendation (SBAR). In the triage area, we reviewed 21 triage assessment records, which were generally complete, although 2 records contained missing data entries.

Between December 2024 to May 2025, data showed that 11 babies were born in triage. Senior staff told us this was mainly related to women unexpectedly delivering within 15 minutes of arrival. The service had pathways and escalation processes in place to minimise the risk of unplanned births in non-labour ward areas. Staff told us when women experienced precipitated labour and delivered in unsuitable locations, they took appropriate measures to ensure their privacy and dignity was maintained.

Staff used a nationally recognised tool to monitor and respond to clinical deterioration. The Modified Early Obstetric Warning Score (MEOWS) was used to identify women at risk, with appropriate escalation procedures in place. Between November 2024 to April 2025, staff achieved 93% compliance in the MEOWS audit, which was above the trust target of 90%.

Staff completed newborn risk assessments when babies were born using recognised tools and reviewed them regularly. The service used the newborn early warning track and trigger (NEWTT) assessment tool. From January to June 2025, staff achieved 98.5% compliance in the NEWTT audit, which indicated strong compliance across all areas including documentation, staff sign off and appropriate action being taken.

Data showed that staff achieved 94.2% compliance in the venous thrombosis (VTE) audit between the months of December 2024 and May 2025 which was above the trust target of 90%.

Staff completed fetal monitoring risk assessments and used the fresh eyes approach to carry out fetal monitoring safely and effectively, in line with national guidance. Leaders audited how effectively staff monitored women during labour on continuous CTG’s. Audit data between January and June 2025, showed 100% compliance in interpretation and management plans and 94% compliance with hourly ‘fresh eyes’ reviews.

Staff assessed each woman’s health when admitted, informed them of risk and how to keep themselves safe.

Staff used the SBAR communication framework to update their colleagues and handover care throughout the unit and recorded this on the electronic patient records. Staff achieved 98% compliance against the trust target of 90% in the December 2024 SBAR audit. The service had not completed a follow-up audit in 2025.

Staff completed the World Health Organisation (WHO) 5 steps to safer surgery checklist prior to starting surgical procedures. Between January and May 2025, staff achieved 99.4% compliance with the WHO audit, which was better than trust’s target of 90%.

Women and their families were encouraged to provide feedback on the service and their care, with staff offering support to do this. Staff also empowered women to make informed decisions about their care and treatment.

The service provided relevant information which were accessible across the maternity unit to promote healthy lifestyles and offer support to women and their families. However, this was not always available in other languages.

Staff made sure women living with mental health conditions, learning disabilities and dementia received the necessary care to meet their individual needs. The service had access to mental health liaison teams and specialist mental health midwife support when staff were concerned about a woman’s mental health. Staff also provided emotional support, guidance and assistance to women and their families when needed.

Shift changes, safety huddles and handovers involved all relevant multidisciplinary staff and consistently included all necessary key information to keep women and babies safe. During our inspection, we observed staff handovers and found that key information needed to keep women and babies safe were clearly communicated.

The service had access to 24-hour translation services including British sign language (BSL) by telephone.

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

The service did not have suitable facilities, to meet the needs of women and their families. Instead, one of the high-risk rooms within the delivery suite was used to support bereaved women and families when needed. The room looked clinical, lacked appropriate furnishings, and did not offer a comforting or homely environment. Additionally, the cold cot was placed in open view rather than in a separate area, which was not in line with national bereavement and the Stillbirth and Neonatal Death Charity (SANDS) recommendations. We also observed that not all the delivery rooms on the labour ward were ensuite, which was not in line with the Department of Health (2013) Health Building Note 09-02 maternity care facilities guidelines. Senior staff told us that there were plans to relocate the maternity service to a new building, which was been built at the time of our assessment and was planned to meet national guideline requirements.

On the first day of our inspection, the maternity theatres were out of operation due to a fault in the theatre ventilation system, which had occurred over the weekend. Due to this, the service was on OPEL 4 diversion. The theatre ventilation system was on the service’s risk register and staff told us about previous issues that had led to short term suspension of theatre activity. However, this was the first time where the theatres had to be closed, and the service placed on divert for several days. The ventilation fault was repaired by the second day of our inspection, and the service returned to normal.

The service did not have enough suitable equipment to safely care for women and babies. Staff told us they did not have enough sonicaids, cardiotocograph, thermometers and lights for suturing, and on occasion to deliver safe and timely care and assessment. Staff gave an example of an occasion where they had to use a torch light when suturing a perineal tear. Staff told us the service did not provide single use underwear and sanitary pads for women, which negatively impacted their experience and potentially increased the risk of infection. The service did not have centralised CTG monitoring in place, which is recommended in national guidelines. This issue was recorded on the risk register and rated as amber. Additional risks related to equipment and environment included size of 6 delivery suite rooms, faulty CTG equipment, ET tubes, rodent infestation, medical gas concerns, a limited number of electric accessible pathways, issues with resuscitaire and gaps in clinical device training.

The design of the environment did not meet national guidance, specifically the Health Building Note (HBN) 09-02 for maternity care facilities. Due to room size limitations, resuscitaire were not available in all labour rooms and were stored outside. This meant that in an emergency, the newborn would need to be carried out of the room and placed onto the lifesaving equipment. This posed a potential risk of hypothermia and falls. Senior staff told us that the new building would have enough space in each labour room for a resuscitaire. This issue had not improved since our last inspection, although a risk assessment had been completed.

Ligature cutters were not available across the maternity unit, and staff had limited knowledge around ligature risks and were unaware of the location of ligature cutters. This posed a potential safety risk for women with mental health needs. This was escalated to the trust as part of our inspection. During our follow-up visit, we found that ligature cutters were available in all clinical areas, and staff we spoke with were aware of their location.

There were birthing pool facilities in both the birth centre and the labour ward, however, the service had not carried out a pool evacuation drill for staff for over 12 months. The lack of regular pool evacuation drills could impact on staff competency, delayed response during an emergency and increase the risk of harm to pregnant women. Legionella water checks were in place, and staff achieved 92% compliance in the birthing pool temperature audit.

Policies and procedures were in place for deep cleaning and decontamination of equipment. Staff stored and disposed of clinical waste safely, which was an improvement since our last inspection. Sharps bins were filled within safe limits, and clinical and domestic waste were correctly segregated and labelled.

Staff carried out daily safety checks of specialist equipment. Between January and May 2025, staff achieved 99.7% compliance for adult resuscitation trolley checks, 97% for resuscitaire checks and 92% for equipment safety and portable appliance testing (PAT) testing. PAT testing ensures electrical appliances are safe for use and helps prevent accidents. Faulty equipment identified during visual checks was decommissioned and replaced.

Women were able to reach call bells and staff responded quickly when called.

Women we spoke with reported they were cared for in safe environments that met their needs.

The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development through annual appraisal.

Staffing levels did not always match planned numbers, putting the safety of women and babies at risk. This remained unchanged since our last inspection. Staffing levels displayed in triage and the postnatal ward was not always up to date. On the day of our inspection, the antenatal ward was short of 1 maternity support worker, and 2 midwives were redeployed from other areas, including the labour ward, to support the postnatal ward due to high acuity. Staff told us low numbers of staff made them feel unsafe.

Between November 2024 and April 2025, the service reported an overall midwife fill rate of 87% for both day and night shifts, and a 67.5% fill rate for the maternity support workers. These figures support the staffing concerns we found during our inspection.

The service reported 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 ‘red flag’ indicates potential concerns with staffing levels. Between November 2024 and April 2025, 362 red flag incidents were recorded. This was a high number and mainly related to delayed or cancelled time critical activity, delays in starting induction and labour ward coordinators not maintaining supernumerary status.

Between October 2024 and April 2025, 99% of women received one to one care in labour by a midwife against a 100% target.

Between October 2024 and April 2025, the service reported 21 diversions to other maternity units, some of which were due to staff shortages. In April 2025 alone, the service was on divert 4 times, which totalled 253 hours and 5 minutes. Following our inspection, we received a qualified whistleblowing concern, highlighting frequent use of the divert status. For example, the service was on divert for 12 days continuously around August and September 2025, coinciding with an industrial action weekend, which had a significant impact on women and the wider region. Communication about diversions was not consistently shared with women and external stakeholders.

An external incident investigation report in April 2025 highlighted concerns related to midwifery and medical staffing. These included an obstetrician failing to respond to a midwife’s call, insufficient midwifery staffing levels, and the absence of a dedicated obstetrician in triage. These issues contributed to delays in the assessment and treatment of a woman.

The service reported 7 staffing related incidents in April 2025. These were primarily due to short staffing, escalation and lack of breaks.

Staff raised concerns about rota management, recruitment and the induction process of midwifery staff. They told us that rotas for permanent staff were not always available in line with the trust’s policy of providing 6 weeks’ notice, often receiving them only 2 to 4 weeks in advance. For example, the July 2025 rota was issued just 3 weeks in advance, while bank staff received access only 1 week in advance. This impacted shift coverage, staff work life balance, morale and the ability to support flexible working.

The service experienced high vacancy, turnover, and sickness rates, alongside significant reliance on bank maternity staff. Between May 2024 and April 2025, the sickness rate for midwifery staff was 7.7%. As of April 2025, the vacancy rate for midwives was 9.5% (22.02WTE), with an additional 13.12WTE staff on maternity leave. Staff told us that many of their colleagues were absent due to maternity leave and short term sickness, which they attributed to workplace stress due to the culture within the service, and on-going human resource issues. Senior staff told us that a recruitment campaign was launched in March 2025 to help cover maternity leave.

Managers accurately calculated and reviewed the number and grade of midwives, nurses, maternity care assistants required for each shift in accordance with national guidance. They completed a maternity safe staffing workforce review in line with national guidance in 2022. This review recommended 239.28 whole-time equivalent (WTE) midwives Band 3 to 7 compared to the funded staffing of 217.1WTE, a shortfall of 22.18WTE staff. The staffing exercise also recommended a birth rate plus ratio of 1:21.1. and the current workforce ratio of 1:26 exceeding the recommended level. Staff told us that as of April 2025, the staffing ratio exceeded both the funded level and the recommendation from 2022 review. Senior staff told us a new workforce review was underway in 2025 and was currently at the factual accuracy stage.

The service allocated a supernumerary labour ward co-ordinator to each shift, responsible for overseeing staffing levels, patient acuity, and ward capacity. Between October 2024 and April 2025, the service reported 99% compliance with maintaining the coordinator’s supernumerary status on the labour ward, against the trust’s target of 100%. However, staff reported that coordinators were not always supernumerary, which at times limited their ability to maintain full overview of the service.

The service also had a designated bleep holder for each shift, responsible for monitoring capacity across the unit. A daily safety huddle was held to review capacity, acuity and staffing across the unit with attendance from midwifery, obstetrics and anaesthetics. However, staff working on the postnatal ward told us they did not routinely have a daily safety huddle. This can result in fragmented understanding of women needs, staffing acuity and potential delays in addressing capacity issue and risk.

The ward manager was able to adjust staffing levels based on the needs of women, using the acuity tool and redeploying staff to areas with higher acuity. However, staff told us that these changes were often made at short notice, and they were sometimes expected to work in areas unfamiliar to them. Staff raised concerns about skill mix, particularly the shortage of band 6 and 7 staff on the labour ward. This impacted the supervision of junior staff, the management of complex case, and leadership during shifts. Limited appropriate skill mix also impacted on the labour ward coordinator’s role to maintain full overview of the service and reduced the level of support available to students and preceptor midwives

Staff, including student midwives, raised concerns that some final year student midwives may not achieve the number of deliveries needed to complete their training programme, potentially leading to delays in completing their qualification. At the time of our inspection, the service did not have a plan in place to support students in meeting this requirement.

Managers requested bank staff who were familiar with the service and ensured all bank and agency staff received a full induction and understood the full operational procedures of the service.

As of May 2025, the trust employed 129.3WTE anaesthetics staff, including 47.1WTE consultants and 24WTE specialist registrars. However, there was no breakdown of the number of anaesthetists allocated to the Maternity service, and staff told us there were ongoing shortages. The lack of anaesthetic staffing contributed to delays in providing epidurals for women in labour, which was recorded on the risk register as an amber rated concern, last reviewed on 23 May 2025. Therefore, we were not assured that the anaesthetic staffing levels and rota met the Anaesthesia Clinical Services Accreditation standard 1.7.2.1, which required a dedicated anaesthetist to be available 24 hours a day, 7 days a week to cover labour ward for elective and emergency caesarean sections. Between June 2024 and May 2025, the trust’s anaesthetics turnover rate was 15.4% and 1% sickness rate. The vacancy rate was 2.6% as of May 2025, the highest vacancy rate was for speciality anaesthetists, at 38%.

The service employed 29.22WTE obstetrics and gynaecology consultants, along with 17.7WTE specialty registrars, 13 senior specialty registrars, and 15 junior and middle grade doctors.

The service consistently had a consultant on call during evenings and weekends. However, the consultants and registrars covered both maternity and emergency gynaecology, which led to delays in the timely assessment of women, particularly in triage. The limited overnight consultant availability due to dual responsibilities across maternity and gynaecology was recorded on the service’s risk register and rated as red.

Medical staff told us they was a shortage of consultants, which impacted on clinical activities, supervision of junior doctors and governance processes. They also reported they did not have enough programmed activities (PA) sessions to undertake essential tasks such as audits, incidents investigations and administrative duties. Additionally, the service lacked a dedicated obstetric sepsis lead. Senior staff told us that the trust board had approved the recruitment of 2 consultants and was reviewing job plans and PA sessions of doctors to enable them to participate in incidents reviews. During our follow-up visit, staff confirmed that 2 hours of PA time had been allocated to 17 consultants, and an additional consultant had been appointed brought in to support governance and incidents investigation within the service.

The service had reducing vacancy rate for obstetrics and gynaecology doctors. The overall vacancy rate for consultants was 8% and 13% for specialty registrar as of May 2025. The service also had high turnover rates for medical staff with a turnover rate of 21% between June 2024 and May 2025. The trust did not specify its target rate for turnover, vacancies or sickness rates. Staff reported frequent short term sickness among doctors, who were also working beyond their contracted hours.

The service had low reliance on bank and locum medical staff. Managers were able to access locum support when additional medical cover was required, and ensured all bank, agency and locum staff received a full induction to the service before they started work.

According to the 2024 General Medical Council National Training Survey (GMC NTS), the service met 17 standards. However, it fell below the national average for regional teaching and received red Rating in this area. In response, the service had an action plan in place focusing on improving regional teaching, clinical supervision out of hours and addressing staff workload.

Managers did not consistently support staff development through regular, meaningful, annual appraisals. Compliance with the appraisal process was significantly low, which negatively impacted on staff development and posed a potential risk to the safety of mothers and babies. Between May 2024 and May 2025, overall staff compliance with annual appraisals was 62.4%, which was significantly below the trust target of 90%. In May 2025, compliance reached 65%, showing no improvement since our previous inspection.

The service did not make sure that all staff completed mandatory training. In particular, medical staff were not always up to date with appropriate mandatory and maternity specific training, against the trust target of 90%. This had not improved since our last inspection.

The service did not make sure that staff consistently received multi-professional simulated obstetric emergency training (PROMPT). As of 10 June 2025, compliance with PROMPT training was 93% for midwifery staff, 89% for anaesthetic staff, 63% for obstetric staff and 64% for nurses and nursery nurses. During the same period, staff compliance with pool evacuation training was 85%, advanced life support training reached 71.4%, newborn basic life support training 87% and neonatal resuscitation training was 89%.

Data showed that as of 31 May 2025, 62% of obstetric doctors and 92% of midwives had completed their CTG training and 98% of multidisciplinary staff had passed the CTG competency test.

The trust told us the low compliance for medical staff was due to the rotation of junior doctors into the unit in April 2025. Those who had not yet completed their training had been booked to attend upcoming trainings. The issue of mandatory training compliance for medical staff was recorded on the service’s risk register.

The service did not complete regular skills and drills sessions for staff in the service. However, staff had undertaken other maternity specific training as part of their ongoing updates. This includes training in diabetes care, bereavement support, smoking cessation, multiple pregnancy, antenatal screening and blood transfusion. Staff told us the mandatory training programme was comprehensive and met the needs of both women and staff.

Midwives were supported by a dedicated practice development team, which included 5 practice development lead midwives and a band 4 lead maternity support worker.

The service assessed and managed the risk of infection. They kept equipment and the premises visibly clean.

Ward areas were visibly clean and furnished appropriately, with most items well-maintained. However, during our visit, we observed 2 worn chairs with tears in triage area, which posed an infection risk to women and their families. The service generally performed well for cleanliness. Between March 2025 and May 2025, staff achieved 97% compliance in cleaning audits. Cleaning records were up-to-date and demonstrated that all areas were cleaned regularly.

Staff had clear roles and responsibilities around infection prevention and control. Daily cleaning was completed by domestic staff and maternity support workers. Equipment was cleaned after each patient contact and labelled with green ‘I am clean’ stickers to show the last cleaning date. Hospital disposable curtains were visibly clean and changed every 6 months, or sooner if soiled or contaminated.

Staff adhered to infection control principles, including handwashing and the use of personal protective equipment (PPE). Between April 2025 and May 2025, staff achieved 96.1% compliance in the hand hygiene audit and 94% in the infection prevention and control audit.

The service also met the standards required under the control of substances hazardous to health (COSHH) Regulations.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Staff did not learn from safety alerts or incidents to improve practice. Staff told us they were not aware of any medicines-related incidents and learning that had occurred in the service or across sister sites in the last 12 months. A backlog of overdue incident reviews remained, and staff were unable to describe any learning or improvement to the service following medicines-related incidents.

Between September 2024 and December 2024, the hospital reported 372 medication related incidents within the service. These were primarily associated with high-risk medicines and included omitted doses of insulin, anticoagulant and antibiotics.

Staff across the maternity service did not regularly monitor the fridge and ambient temperature for medicine storage in accordance with the trust’s policy. For example, during inspection, we identified a 10% gap in the medicine’s fridge temperature checks within the theatre area. Between December 2024 and May 2025, overall compliance with fridge temperature monitoring was 85.3%. Notably, one community team demonstrated low compliance 59%.

A dedicated pharmacist provided support for medicines optimisation, while the pharmacy team managed medicines supply and stock control during weekdays. However, weekend support from the pharmacy department remained limited due to funding constraints. Staff we spoke with told us this had an impact on the timely provision of discharge medications. Pre-packaged medicines commonly required for discharge, were available on the wards to help mitigate some of the delays in discharge.

We found prescription stationery was not stored securely in the Maternity Day Assessment Unit (MDAU). The lead pharmacist told us this issue had been identified in a previous internal audit, but the stationery had not yet been returned for secure storage.

Staff followed systems and processes to prescribe and administer medicines safely. At our last inspection, we found staff were not consistently documenting patient weights on paper medicines administration records (MARs). On this inspection, we saw that electronic MARs (eMARs) had been implemented. Patient weight and venous thromboembolism (VTE) risk assessment records were now mandatory fields before prescribing.

Medicines were clearly recorded on the eMAR and staff documented reasons for any omissions or delays in medicines administration. The trust was in the process of developing a dashboard to monitor missed doses as an area for further improvement. Patients we spoke with said they received medicines at the correct times, and one patient told us their pain relief was provided promptly when requested.

Staff reviewed each woman’s medicines regularly and provided advice to women and carers about their medicines. Staff followed national practice to check patients had the correct medicines when they were admitted or they moved between services.

At our last inspection, medicines were not always stored safely. On this inspection, we saw that medicines, including controlled drugs (CDs), were stored securely. Following a recent CD related incident, governance arrangements for the management of CDs had been further strengthened, and staff were fully engaged with the new processes. Emergency medicines were available and accessible in line with trust policy. Liquid medicines in use were clearly labelled with opening and expiry dates to support safe administration.

Qualified staff were able to supply medicines under Patient Group Directions (PGDs) and through midwife exemptions. This supported timely access to medicines without requiring a prescription. However, staff told us that expanding PGDs, for example, to include iron supplements, would further support timely discharges.