Bedford 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 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 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 staffing, relating to the management of triage and medical staff training compliance. At this assessment, the service was in breach of staffing and safe care and treatment, relating to system management in triage, abduction risk management, staff training and appraisal compliance.

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 had a proactive and positive learning culture, based on openness and honesty. However, incidents and duty of candour were not always managed in a timely manner.

The service had an incident reporting system that was accessible to staff. All staff we spoke with onsite knew what constituted an incident, how to report it, and felt comfortable doing so. However, some staff reported they did not consistently receive feedback following incidents they reported. In response, the service had introduced a new feature within the incident reporting system that enabled staff to request feedback.

Staff understood the duty of candour and reported they were open and transparent with women and their families when things went wrong, providing full explanations. However, the service did not always meet the trust target of 100% for duty of candour. Duty of candour had 3 stages, compliance was 84% for stage 1, 80% for stage 2 and 71% for stage 3 at the time of the assessment. This meant we could not always be assured that the service was creating culture of transparency, trust, and accountability in a timely manner. This had been identified on the risk register and senior leadership informed us that the trust had a duty of candour task and finish group in place to improve compliance.

Between June 2024 and May 2025 1,950 incidents were reported through the incident reporting system. The service reported that 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 287 incidents open. Of these, 163 had been open for over 30 days and 67 incidents had been open for 60 days. Four of these incidents exceeded the trust’s target of 6 months for a full investigation. This showed there had been no improvement since our previous inspection. In response, the governance team told us there was ongoing work to close all outstanding incidents. This included midwifery staff picking up bank shifts and doctors being allocated extra time to review incidents. Incidents were reviewed at a local level and were closed if they were deemed low harm. If the incidents were moderate or above with concerns, they were reviewed at the trust patient safety panel to determine whether a full investigation was required. Meeting minutes we reviewed showed the panel met weekly and covered incidents from all areas within the trust.

Staff reported they received feedback of themes from incidents and complaints through governance meetings, monthly newsletters and during team meetings. We reviewed various team meeting minutes from different areas within the unit but found incidents were only discussed at the maternity ward team meetings. However, we did observe Incidents and complaints being discussed in governance meeting minutes.

Staff feedback was acknowledged and acted upon by the service. For example, the service implemented changes to the support provided to preceptorship midwives. These included but were not limited to the introduction of one-to-one meetings and monthly drop-in sessions.

The service did not establish and maintain safe systems of care. They did not always make sure there was continuity of care, including when people moved between different services.

The service did not consistently ensure that triage care systems aligned with national guidance. Most of the women admitted to the maternity unit were initially assessed through the maternity triage. Triage was staffed by one midwife from the core team and a maternity support worker, which was aligned with the Royal College of Obstetricians and Gynaecologists (RCOG) guidance outlined in the ‘Maternity Triage, Good Practice Paper’, based on the annual birth rate. However, the maternity triage service used a triage tool to assess women on arrival, a model which required the presence of two midwives. To remain compliant with the triage tool staffing, the service requested a bank midwife from ‘11am to 11pm’ to support the triage service, however this shift was not always filled and always left only one midwife overnight.

During our assessment, we observed that triage responsibilities were too extensive for midwives to manage safely. This issue had not improved since our previous inspection. Triage functions included both face to face assessments and monitoring of the maternity triage line. This arrangement did not align with the RCOG: ‘Maternity Triage, Good Practice Paper’, which recommends a dedicated midwife assigned specifically to the telephone line in a separate dedicated area.

The telephone triage line was intended to provide access to the unit for women with concerns. However, during our assessment, triage was busy, resulting in some calls not being answered. Additionally, we observed a non-qualified member of staff answering calls, which did not align with established guidance. Data provided by the trust showed there were 2097 incoming calls in March 2025, of which 451 calls were either abandoned or left unanswered. This posed a risk to women who were trying to access the service because of concerns. We escalated this concern to the leadership within the service, who confirmed they had plans to establish a private location for the telephone triage line with a dedicated midwifery team by September 2025.

A triage tool was used to assess women presenting to the unit with pregnancy related concerns, enabling prioritisation based on clinical need. The system used a red, amber, green (RAG) rating approach, with assessments documented on paper. According to the triage tool guidelines, women should be seen by a midwife within 15 minutes of arrival and categorised as red, orange, yellow or green. Each category indicated the urgency for review by a doctor or midwife. A red rating required immediate transfer to the labour ward, orange required a review within 15 minutes, yellow within 1 hour and green within 4 hours.

Data provided by the trust indicated full compliance with the 15-minute initial midwife review target in March and April 2025 and 98% compliance in May 2025. Compliance with reviews by the appropriate clinician, in line with the RAG rating was 88% in March, 100% in April and 93% in May 2025. Compliance for an appropriate follow up and plan being made was 100% in March, April and May 2025. Although the trust did not confirm the target benchmark for this audit, the results demonstrated an improvement since the previous inspection.

The service did not consistently ensure continuity of care for women. Staff reported frequent delays transferring women to the labour ward during their induction of labour (IOL). Induction of labour is the process of artificially starting labour, the process usually begins on the maternity ward before women are transferred to the labour ward to either continue with the next step of the IOL or labour and deliver their baby. The trust did not provide data on IOL delays, so it remains unclear whether any actions are being taken to address this issue.

Staff reported having timely access to patients notes which were paper notes, diagnostic results and the electronic medicine system. However, during our assessment, we observed that women’s notes on the maternity ward were not always stored securely. We escalated this concern to the trust, and by our second visit, this issue had been addressed.

Staff did not consistently follow current policies. At the time of our assessment there were 9 hospital specific guidelines and 7 cross-site guidelines that were out of date. These guidelines included but were not limited to abduction or suspected abduction of an infant or baby, management of post-partum haemorrhage and obstetric sepsis management. This demonstrated no improvement since our previous inspection. We escalated this issue to the trust, who attributed the delays in guideline review to limited capacity among multidisciplinary staff due to clinical workload pressures. During our follow up visit, the trust had made some progress with updating some guidelines and had a plan to update the remaining outdated documents.

Staff did not prevent the risk of baby abduction within the service. Staff did not always complete training on how to recognise and report abuse or follow up to date trust guidance.

The maternity ward had security measures in place to prevent baby abduction which included a baby tagging system, controlled access to all areas, and ward clerk coverage from ‘8am to 4pm’. However, staff did not always follow the required procedures. Although the ward was equipped with an intercom system at the main entrance, allowing staff to control entry and exit, during our assessment we observed that staff did not routinely challenge individuals requesting access, which posed a potential risk of abduction. We escalated this concern to the trust, who advised that a reminder would be sent out to all staff. At our follow-up visit, we observed an improvement, with staff challenging all individuals prior to enabling them to gain entry to the ward.

We also observed that access between the maternity and the gynaecology wards was not adequately controlled, with only a single point of entry located through the maternity ward. This presented an additional abduction risk, as staff from the gynaecology ward were able to operate the intercom system without necessarily knowing which individuals were authorised to enter.

At the time of our assessment, the baby abduction policy was out of date. The most recent baby abduction drill, conducted on 15 April 2025, resulted in a simulated abduction being successful. Staff demonstrated limited knowledge of the correct procedure s during the exercise. As a result, safety actions were recommended and are currently being implemented.

Staff did not always complete training specific for their role on how to recognise and report abuse. The service provided medical and midwifery staff with level 3 safeguarding training for children and adults. At the time of our assessment, the overall compliance rate for this training for medical staff was 85% and the overall compliance rate for midwifery staff was 86%. Both of which did not meet the trust target of 90%. This showed there had been a deterioration since our previous inspection. The trust reported this was due to the clinical workload impacting on staffs' ability to attend training and they reported there would be increased oversight to improve compliance going forward.

The service had a named safeguarding midwife for maternity, who played a key role in overseeing safeguarding cases, supporting staff and facilitating training sessions. During this assessment we identified that the trust wide adult safeguarding policy had been out of date since May 2024, raising concerns about the reliability and accuracy of its content. At our follow up visit we noted that the policy had been reviewed, and the review date had been extended for 6 months as it was deemed appropriate and fit for purpose.

Staff we spoke with demonstrated a clear understanding of safeguarding procedures including how to make a safeguarding referral and escalate concerns appropriately. They were able to provide examples of how to protect women from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff also showed awareness of how to identify adults and children at risk of or experiencing, significant harm and knew where to document and access relevant information. Additionally, staff reported the safeguarding team was very visible and could easily identify the safeguarding lead.

The service did not always work well with people to manage risks assessments in line with national guidance.

Women’s notes were not always fully comprehensive. At the time of our assessment, the service was using used paper- based patient records, with plans to implement an electronic patient record system in 2026.

We reviewed 3 sets of women’s records and found that staff did not consistently assess whether each woman and birthing person was high or low risk at the time of booking. As a result, we could not be assured that individuals were receiving care appropriate to their level of risk. Additionally, risk assessments were not always completed at every antenatal appointment, which raised concerns about whether appropriate referrals were always being made. This issue remained unchanged since our previous inspection.

Staff did not always use a nationally recognised tool to identify women at risk of deterioration. Women’s notes we reviewed during the assessment were not always completed in line with guidance. However, audit data showed high compliance across all areas, with 95% in March, 94% in April and 97% in May 2025 for both documentation and accurate scoring of the MEOWs charts.

Staff did not always complete the World Health Organisation (WHO) 5 steps to safer surgery checklist prior to starting surgical procedures. During our assessment, we reviewed 2 checklists that contained incomplete documentation. This checklist outlines key safety checks to be performed before, during and after a surgery to ensure patient safety. However, audit data provided by the trust showed 100% compliance with the use of the WHO checklist between March and May 2025.

Staff did not consistently complete fetal monitoring risk assessments in line with national guidance. During labour, high-risk women were monitored using cardiotocograph (CTG), a tool used to monitor fetal heart rate and uterine contractions. According to the National Institute for Health and Care Excellence (NICE) guidelines NG229, women attached to a CTG during labour should receive an hourly ‘fresh eyes’ review where 2 clinicians independently ass the CTG trace and document their findings ensure the baby is safe to continue with labour.

Hourly completion of fresh eyes reviews was not consistently documented in the notes we reviewed during our onsite visit. Audit data demonstrated a downward trend in compliance with 91% in January, 84% in February and 78% in March 2025, all of which were below the trust target of 90% which supported what was found onsite. In response, the trust submitted an action plan aimed at improving compliance and included initiatives such as a full day training session and enhanced monitoring measures.

Staff completed newborn risk assessments at birth and reviewed them regularly. The service used the newborn early warning track and trigger (NEWTT) assessment tool. Audit data indicated strong compliance across all areas, with 100% in April, 100% in May and 96% in June 2025 for documentation, staff sign off and appropriate action being taken.

For women who did not require continuous CTG, foetal heart was monitored using a doppler device through a method known as intermittent auscultation. Audit data demonstrated strong compliance: 100% in January, 95% in February and 100% in March 2025, which exceeded the trust target of 90%.

Handovers and safety huddles we observed across the unit involved all relevant members of the multidisciplinary team, were structured and held in an area with minimal disruptions. Shift changes and handovers included all necessary key information to ensure the safety of women and babies.

Staff provided timely emotional support, guidance and assistance to women and those close to them. Individuals with mental health conditions or learning disabilities received tailored care to meet their specific needs, supported by a dedicated mental health midwife and access to mental health liaison services.

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

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

The unit was open 24-hours a day, 7 days a week and maternity services at the hospital included an antenatal clinic, triage, day assessment unit, labour ward and birth centre and a maternity ward. All corridors were brightly lit and free from clutter. However, the overall design of the environment did not consistently align with national guidance or adequately support the number of women attending the unit.

The triage waiting area on labour ward was limited to just 2 seats, requiring lower risk individuals to wait at the reception outside of the clinical area. This arrangement did not meet the recommendations outlined in the RCOG: Maternity Triage, Good Practice Paper which advises the waiting area should be ‘Appropriately sized and ideally visible to clinical staff’. To improve oversight the service had installed CCTV monitoring of the external waiting area.

During the COVID19 pandemic, a delivery room within the delivery suite was repurposed for a second theatre. However, in July 2022 it was deemed unsuitable for use due to inadequate air changes, lack of temperature control and insufficient space. This issue was identified at our previous inspection and has remained on the service’s risk register since July 2022. Following escalation, the trust reported that the second theatre had only been used in emergencies to mitigate risk, and over the previous 6 months, it had been used 12 times for emergency caesarean sections and trial instrumental deliveries.

The service operated an elective caesarean section list from Monday to Friday for women who were high risk and unable to labour. These procedures were performed in theatre 1; however, emergency cases were given priority, resulting in the elective list being paused to avoid using the delivery room theatre. Staff reported that this negatively impacted capacity, access and flow often preventing completion of the list before the dedicated elective caesarean section team ended. Data provided by the service indicated the elective caesarean section list had been paused 32 times in the last 6 months. This resulted in the list being delayed as the elective caesarean team often could not complete it within their shift, and the on-call team often having to take over. This negatively impacted acuity and flow within the service.

A recent ligature risk assessment was conducted across the unit, confirming that all call bells were ligature free. However, during our assessment, staff were unable to identify the location of ligature cutters and demonstrated limited understanding of ligature risks. This was escalated to the trust, which initiated a practice alert to all staff. 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.

Birthing partners were welcomed and supported to attend births and provide care and reassurance women across all areas of the service. In the event of a fetal loss, the service offered bereavement facilities to support families. While the bereavement room was suitably equipped to meet the needs of families, it was not soundproof and was located directly opposite a labour room. This arrangement did not align with national bereavement recommendations, which advise that bereavement spaces should be soundproofed and offer complete privacy and comfort.

The service did not have sufficient equipment to safely care for women and babies. At the time of our assessment, there were only 6 resuscitaires available for 8 labour ward rooms. This posed a risk of unavailability during an emergency. In response, the service had purchased 2 new resuscitaires which we observed were stored in a corridor. Staff reported that although the resuscitaires had been delivered months prior, they were not yet in use due to incomplete training. At the time of our assessment, training compliance stood at 72%. We escalated this to the education team and they confirmed they would investigate further.

Staff mostly completed daily checks on emergency and safety equipment, which included neonatal resuscitaires and adult resuscitation trolleys. These checks were recorded using an electronic system. Data provided by the trust showed 96% compliance for adult resuscitation trolleys across the unit and 99% compliance with neonatal resuscitaires. However, during our assessment expired medication was found in the cardiac trolley on the ward and an out-of-date consumable was identified on 1 of the resuscitaires. Both issues were escalated and addressed immediately. Additionally, the placement of the adult resuscitation trolley was noted to block access to the gynaecology ward.

Women were able to access call bells, and staff responded promptly when called on the maternity wards. Clinical waste was disposed of safely; sharps bins were observed to be filled within safe limits, and clinical and domestic waste were correctly segregated and labelled.

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 yearly appraisal.

The service did not always have enough midwifery and medical staff to keep women and babies safe. On the first day of our assessment the numbers of midwives and maternity support workers did not meet planned numbers, with a shortfall of 1 midwife and 2 maternity support workers on the day shift and 1 midwife on the night shift. This led to redeployment to maintain cover. During our follow up visit, the unit remained short staffed, with 1 maternity support worker on the day shift and 2 midwives on the night shift. In contrast, medical staffing met planned levels during both our assessment and our follow up visit.

The service had a designated bleep holder responsible for overseeing capacity and acuity throughout the shift. The service used the birth rate plus acuity tool to calculate the number of midwives required across the maternity unit. These calculations were carried out every four hours in intrapartum areas and every six hours on the maternity ward by the midwife in charge. A daily safety huddle was held to review capacity, acuity and staffing across the unit with attendance from midwifery, obstetrics and anaesthetics.

Staff reported staffing remained a significant concern, negatively impacting morale and contributing to increased sickness levels. Staffing issues were regularly logged through the trust’s incident reporting system, with 16 incidents recorded in February, 8 in March, and 6 in April 2025. In response, the service commissioned a midwifery workforce review using birth rate plus in January 2025 to identify whether an uplift in staffing was required. At the time of our assessment, the findings of this review had not yet been published.

The service monitored maternity staffing incidents classified as ‘red flags’ in line with the NICE guideline: Safe Midwifery Staffing for Maternity Settings. A midwifery ‘red flag’ indicates a potential issue with staffing levels. Between February and April 2025, the service recorded 56 red flag events. The most frequent red flags event included the coordinator being unable to maintain supernumerary status, delays between admission and the start of induction of labour and delayed or cancelled time critical procedures. The service reported there was ongoing recruitment to support the reduction of red flag events.

Between February and April 2025, the service experienced an increase in vacancies and a decline in sickness rates. The overall maternity staff vacancy rate increased from 3.12% in February to 6.46% in March, reaching 7.55% in April. Meanwhile, the overall sickness rate decreased from 12.6% in February to 8.43% in March and 6.94% in April 2025. The trust did not specify its target rates for vacancies and sickness.

The service reported regular use of bank midwives and infrequent use of agency staff. All bank, agency, and locum staff received a full induction and were familiar with the service.

The trust delivered comprehensive maternity specific and statutory mandatory training that met the needs of women and staff. However, not all staff consistently completed the training. Overall compliance with maternity mandatory training among nursing, midwifery and medical staff was 90%, meeting the trust’s target. However, compliance with key specialist training areas such as practical obstetric multi-professional training (PROMPT), fetal monitoring or neonatal resuscitation training did not always meet the trust target. PROMPT training compliance was 79% for nursing and midwifery staff and 77% for obstetric staff. Fetal monitoring compliance was 84% for nursing and midwifery staff and 91% for medical staff. Neonatal resuscitation training compliance was 82% for midwifery staff, against a trust target of 90%. The education team had oversight of training compliance and reported organising monthly training sessions to improve compliance.

Managers did not consistently support staff to develop through annual, constructive appraisals. Appraisal compliance rates were 74% in March, 76% in April and 67% in May 2025. The trust did not provide appraisal compliance data for medical staff or specify its target compliance rate.

The service assessed and managed the risk of infection.

Ward areas were visibly clean, and the furnishings were well-maintained. Daily cleaning was completed by domestic staff and maternity support workers. Domestic staff had a cleaning schedule they followed and an up-to-date cleaning record to demonstrate all areas were cleaned regularly. The service complied with control of substances hazardous to health (COSHH) standards. Staff cleaned equipment after patient contact and labelled equipment with green ‘I am clean’ stickers to show when it was last cleaned. The service performed well for cleanliness. The service provided cleaning audit data from March to May 2025. The overall compliance for all areas across the unit was 99% in March, 99% in April and 100% in May 2025.

To mitigate the risk of pseudomonas, birthing pool water was flushed daily. Audit results showed 95% compliance between March and May 2025.

Staff had clearly defined roles and responsibilities regarding infection prevention and control. We observed staff following infection control principles, including the use of personal protective equipment (PPE) and hand hygiene. Hand hygiene audits demonstrated good compliance, with 100% across all areas from March to May 2025. We observed hand washing stations and alcohol-based hand sanitiser was available throughout the unit.

Women scheduled for elective caesarean sections were screened for Methicillin- resistant Staphylococcus Aureus (MRSA) during their pre-operative assessment. 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 medicines and treatments were stored securely and managed appropriately.

Staff mostly followed systems and processes for the safe prescribing and administration of medicines. Prescriptions were managed through an electronic patient record (EPR) system. We reviewed 10 records, and they showed allergies and weights were always documented to ensure medicines were prescribed safely and, medicine charts were fully completed by staff when administering medicines. However, on 1 EPR, medication had been omitted with no documented explanation.

Medication was stored securely in locked clinical rooms; this was an improvement from our previous inspection. Staff monitored ambient, fridge and freezer temperatures where medicines were stored, and staff we spoke with demonstrated awareness of escalation procedures when temperatures fell outside safe ranges.

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.

All preceptorship midwives received medicines management training, and all staff received training to use the EPR system. The trust also provided eLearning for administration of intravenous (IV) medication. However, the service did not provide any data on training compliance.