Scarborough 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

At our last inspection we rated this key question as inadequate and this had improved to good at this assessment. This meant women were safe and protected from avoidable harm.

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that women were safe and protected from bullying, harassment, avoidable harm, neglect, abuse, and discrimination.

In this assessment we found continuing breaches of Regulation 12 - Safe care and treatment in relation to training compliance, and Regulation 18 - Staffing in relation to appraisal rates. We found a new breach of Regulation 15 - Premises and Equipment in terms of theatre recovery areas and theatre noise levels and ventilation monitoring.

Despite these breaches, the service had made sustained improvements across multiple areas since the last inspection. This included strengthened incident management, safer and more consistent triage, up to date fire risk assessments, full compliance with baby tagging and PROMPT training, and a more stable medical and midwifery staffing.

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 demonstrated a proactive and positive culture of safety, based on openness, honesty, and continuous learning. Staff felt able to raise concerns, incidents were investigated, and learning was used to identify and embed good practice.

The service had made sustained improvements to its incident management processes. Incidents were reviewed effectively, clear actions were identified, and learning was shared through established feedback mechanisms. These improvements addressed the concerns from the previous inspection, ensured timely oversight, consistent scrutiny of clinical care and a proactive approach to identifying learning and strengthening safety. This resolved the breach of Regulation 17 - Good Governance.

Staff described a stronger learning culture and felt empowered to report safety events, reflecting improved psychological safety and more effective reporting systems. They understood what to report and participated in incident training sessions including Patient Safety Incident Response Framework training, which supported improved confidence and competence.

Daily oversight of maternity incidents was maintained through weekday incident review meetings and safety huddles, with cases escalated to the maternity case review meeting when required. Learning responses were agreed and external reporting completed where appropriate, and incident data, harm levels and learning were monitored through maternity governance structures with escalation into trust wide forums when needed.

The Maternity Assurance Group provided additional oversight of safety event data, harm levels, and learning responses.

Staff were supported by regular feedback and hot debriefs led by the Professional Midwifery Advocates (PMA)’s, providing brief real time reflections following incidents to identify immediate learning, support staff wellbeing and strengthen the wider learning culture.

Learning from incidents, reviews, complaints, and concerns was shared through weekly bulletin updates, patient safety briefings and short safety updates at handovers and huddles with clear messages reinforcing key safety priorities.

Learning from Avoiding Term Admissions Into Neonatal units (ATAIN) reviews was shared through dedicated newsletters, and staff held weekly meetings supported by quarterly audits. Staff gave examples of changes to practice and updates to guidance made as a result.

Staff demonstrated understanding of Duty of Candour principles and ensured openness and honesty when incidents occurred. The service had strengthened its processes, with day to day oversight from the governance teams and a further audit was scheduled for May 2026 to monitor ongoing compliance.

Staff consistently operated effective processes that supported safe, coordinated care and continuity across pathways and transitions and collaborated with patients, relatives, and healthcare partners to maintain safety during admissions, transfers, and discharges.

The service had standard operating procedures to support safe and effective patient flow.

Ward leads attended daily safety huddles that followed a standing agenda covering key operational issues. For example, staffing arrangements, home birth plans, planned caesarean sections, induction of labour, patient transfers, triage activity and breaches, and the Operational Pressures Escalation Level (OPEL) status. This ensured complete oversight with no gaps, with all sites working closely together to maintain safety for all women.

We observed regular and effective handover meetings, pre-operative safety briefings and ward rounds attended by relevant staff who shared information and escalated concerns.

Staff routinely discussed key information to maintain safety, including clinical observations, obstetric risk factors, and safeguarding concerns, which were documented promptly.

Weekly theatre production meetings were used to coordinate elective caesarean section activity across both sites, supporting proactive planning and helping to minimise changes to planned activity.

Elective caesarean sections were scheduled into three dedicated slots on Monday, Wednesday, and Friday, which provided predictable scheduling and consistent access to planned birth.

Community leaders attended morning huddles to review potential discharges from postnatal wards, prioritising women who required home visits and allocating community midwives accordingly. This provided effective safety netting at key transition points and supported consistent oversight across the pathway.

The antenatal day unit supported a broad range of attendances, including scheduled antenatal appointments, scan review follow ups, women presenting for induction of labour and preoperative assessments.

The antenatal clinic ran alongside the day unit and offered specialist clinics in maternal medicine, diabetes, and pre-term birth prevention. Women reported positive continuity, with many having the same community midwife throughout pregnancy and being able to contact them easily.

Staff described strong support from medical staff and specialist teams such as the tissue viability nurses. There was always a consultant obstetrician and anaesthetist on call for obstetric emergencies.

A dedicated team worked in triage and followed a standard operating procedure to support rapid assessment, prioritisation, and escalation. Staff used the Birmingham Symptom Specific Obstetric Triage (BSOTS) framework to support consistent risk assessment. In February 2026 overall compliance with completing the rapid assessment within 15 minutes was 95% which met the target.

Red flag cases are situations where a woman presents with symptoms or concerns indicating potential deterioration or increased clinical risk that require immediate assessment or escalation. These had improved to meet the 5% target demonstrating timely recognition and escalation of risk.

We observed telephone and face to face triage reviews and women were given clear advice on when and how to seek urgent help. Women told us the triage service was easy to contact and described the responses as “reassuring,” “immediate” and “supportive.” However, data showed women reported difficulty getting through to the triage line and the service monitored call abandonment and call waiting data to identify risk and inform improvement actions.

Overall, these improvements strengthened the safety and consistency of the triage pathway and the service was no longer in breach of Regulation 12 Safe care and treatment in relation to triage.

The service recognised that reliable digital systems were essential for safe coordination of care. Poor Wi-Fi and mobile connectivity in some rural and coastal areas affected access to digital records, so the service changed its mobile network provider and digital midwives supported community teams with agreed workarounds to maintain safe communication, record keeping, and continuity of care.

Clinical pathways were clear, up to date and supported safe and effective care.

The service offered two outpatient induction of labour slots each morning and worked flexibly around women’s availability. Women returned 12 hours after the initial assessment, a reduction from the previous 24 hour interval identified at the last inspection, bringing the pathway in line with recommended guidance and supporting timely progression of induction.

Delivery suite performance data for March 2026 included 114 births, 42% inductions, 2% of labours delayed more than 24 hours, 4% of Apgar scores below 7 at five minutes and 7% unexpected term admissions to the special care baby unit.

The antenatal service offered specialist maternity related clinical appointments, including maternal medicine and diabetes clinics. Performance information for March 2026 showed no clinic overruns or delays over 30 minutes, supporting timely review and continuity. However, there was no evidence of coordinated or combined appointments for women with cardiac conditions, meaning they often attended separate appointments rather than receiving a streamlined multidisciplinary review.

Senior leaders told us there had been occasions when the maternity ward closed for admissions, although it had not closed in the past month. They described clear escalation processes and communication pathways to ensure women were redirected safely when this occurred. In April 2026, new guidance was implemented to strengthen processes for managing a labour ward closure, including coordinated consultant to consultant discussions to support safe cross site transfers of women in labour.

Daily antenatal clinics had a named consultant to support continuity of clinical oversight.

The service worked effectively with women to understand and manage safeguarding risks. Staff provided care to meet women’s needs that was safe, supportive, and enabled people to do the things that mattered to them.

Staff demonstrated a good understanding of safeguarding procedures and used the reporting systems to make alerts and referrals. They routinely assessed women at every contact for changes in psychological or emotional wellbeing and checked for any safeguarding risks.

Midwives had access to safeguarding advice and guidance 24 hours a day, seven days a week, with out of hours support from local authority emergency duty teams and senior clinical oversight from two named doctors for safeguarding children.

Staff worked closely with the safeguarding team, who provided responsive advice, face to face training, quarterly supervision, and input into the preceptorship programme.

Training was informed by learning from recent rapid reviews, helping staff maintain confidence in managing safeguarding concerns. Safeguarding lead midwives supported staff to complete referrals and attended pre-discharge meetings when required. Some staff reported that leads were not always visible, and this had been raised with senior leaders.

Women and families were supported throughout the safeguarding process and were offered debriefs and copies of safeguarding reports.

The service shared a quarterly safeguarding newsletter celebrating good practice and recognising safeguarding stars.

Care records showed appropriate documentation, with concerns recorded on the digital system which generated clear flags and alerts to support follow up. This included any instances of female genital mutilation (FGM), which staff documented to ensure appropriate clinical care and safeguarding oversight. The service used bespoke FGM data to monitor trends and strengthen partnership working.

Safeguarding midwives shared learning from the HALO Project, a specialist organisation supporting victims of FGM, forced marriage and honour-based abuse, and delivered training to improve staff awareness and multi-agency working. This strengthened staff confidence in recognising and responding to these forms of harm.

Safeguarding training was specific to staff roles. Compliance was strongest for adult and children’s safeguarding level 1 at 99% and for children’s safeguarding level 2, which exceeded the 90% target. Adult safeguarding level 2 and children’s safeguarding level 3 were close to target, although children’s safeguarding level 3 remained low at 65%. All safeguarding policies were clear and comprehensive.

Safeguarding midwives and the trust’s domestic abuse liaison team delivered training to community midwives to support routine enquiries into domestic abuse, increasing staff confidence and ensuring sensitive, person centred conversations with women.

Specialist bereavement midwives worked closely with local authority safeguarding teams and social services to support families with complex needs.

Staff worked with women to understand and manage risks and supported safe involvement in decisions about their care.

Staff used the Operational Pressures Escalation Level (OPEL) scoring system to identify capacity related risks in real time such as increased activity or staffing pressures which could affect safe care. This triggered senior oversight to ensure risks were reviewed and managed promptly.

An improvement was made in the timely observations of Modified Early Obstetric Warning Scores which are used to identify early signs of deterioration. Compliance met the 90% target for observations completed on time with documented reasons for delays and scores calculated correctly. The most recent audit from January 2026 showed all risk assessments were completed and all identified risks were documented. However, some escalations were delayed and not all cases followed the expected escalation pathway. Audit data was not collected during February or March because the service was introducing an updated audit chart and a revised process for monitoring compliance.

Significant improvements had been made to the triage pathway, ensuring women received timely advice and safe assessment from their first contact.

Staff demonstrated good practice in identifying and monitoring risks and escalating them when required. Care records showed no gaps in completed risk assessments and showed that risks were discussed with women. Identified risks such as mental health needs, allergies and relevant antenatal indicators were clearly recorded which generated automatic alerts to ensure these risks were visible to all staff involved in ongoing care.

The antenatal clinic offered pre-assessment appointments for all planned procedures, including consent discussions, anaesthetic checks, and preparation for discharge. This ensured women were fully informed and supported meaningful involvement in decisions about their care.

Specialist midwives provided targeted input, including visits to women in prisons and asylum accommodation, helping women understand risks and access safe, coordinated care.

Staff felt confident escalating concerns and involving senior colleagues, which supported timely decision making and helped women manage their care safely.

The environment was not consistently safe, and ongoing constraints continued to compromise timely access to care.

There were operational risks in relation to maternity theatre flow and staffing at times of increased demand when women in labour needed to be transferred to main theatres for emergencies when the maternity theatre was in use. Leaders developed a standard operating procedure to support access to main theatres when required. However, staff raised concerns about time delays and the availability of staff to ensure safe transfer of women in labour using the lifts, helping with transfers, and relocating maternity related theatre equipment. Staff also told us that accessing an additional surgical team at short notice could be challenging. A further business case had been developed to relocate elective caesarean sections from the maternity theatre to main theatres to improve capacity, reduce delays and strengthen the resilience of emergency theatre access.

The maternity theatre environment did not meet Health Technical Memorandum (HTM) 03 01 requirements for environmental separation, noise control, and ventilation monitoring. There was not a separate post anaesthetic care unit, noise levels in the preparation and recovery areas exceeded limits due to air leakage around window frames, and the ventilation system had not yet been fully integrated with the building management system. This meant the service was in breach of Regulation 15 - Premises and Equipment. Plans were in place to refurbish the area and create a compliant recovery space by June 2026.

Recent ward assurance data showed gaps in resuscitation checks and oxygen and suction daily checks, which required continued monitoring.

Controlled substances hazardous to health (COSHH) items were not always stored safely. We found two unsecured cleaning products in an unlocked utility room and kitchen, which was escalated and resolved immediately.

Avoidable fire safety risks were present. Several fire doors were found wedged open, which was not in line with trust procedures. However, fire risk assessments were consistently up to date, clearly assessed and documented, with no significant risks identified. Staff had access to clear fire action flowcharts and emergency evacuation plans in all clinical areas, and fire safety awareness training met the trust target of 90%. These improvements meant the service was no longer in breach of Regulation 17 - Good Governance.

All areas visited were clean, organised, and free from clutter. Consumables were stored tidily and labelled, and a small number of out of date items found in one storeroom were removed immediately. Resuscitation trolleys were accessible, tamper evident and regularly checked, and the emergency grab bag in antenatal clinic was maintained to the same standard.

Staff had access to appropriate bariatric equipment, including beds and chairs, supporting safe and dignified care for women with higher Body Mass Index (BMI).

Electrical equipment had been safety tested within the last 12 months, oxygen cylinders were stored securely and staff reported having sufficient equipment to carry out their work safely. There were enough cardiotocography machines, central monitoring, and telemetry equipment, meaning the service was no longer in breach of Regulation 12 - Safe care and treatment.

Community midwives told us that weighing scales and other equipment were calibrated regularly by the trust’s medical engineering teams, and they reported good access to repairs and additional equipment.

The maternity unit was clearly signposted and easy to navigate. The entrance to the labour unit and wards was monitored by CCTV and accessible by swipe card only, supporting a secure care environment. The new triage waiting area did not have a call buzzer, although it was located directly adjacent to the midwives’ station and staff maintained regular visual oversight. A poster advised women to seek help if needed, although the absence of a dedicated alert system represented a potential gap in immediate escalation.

Staff were familiar with the baby abduction process and the tagging procedures used to keep newborns safe. All babies were now security tagged, meaning the service was no longer in breach of Regulation 12 - Safe care and treatment.

The infant and child abduction policy had passed its review date but remained in use while multi-agency updates were being coordinated.

A comprehensive estates plan was in place, including improvements to baby tagging infrastructure and swipe access, and further work was planned to include a full roof replacement supported by a three phase decant plan to maintain safety during the works.

Ward environments were personalised and supportive, with care related information clearly displayed.

However other parts of the maternity theatre environment had improved since the last inspection. Theatre entrance doors had swipe card access and clear signage to support safe access control. The most recent ventilation inspection in May 2025 confirmed compliance with other HTM 03 01 airflow standards, and previous gaps in the Health Building Note (HBN) 09 02 maintenance schedule had been addressed.

The service did not always make sure there were enough qualified, skilled, and experienced staff. They did not always make sure staff received effective support, supervision, and development. However, staff worked together well to provide safe care that met women’s individual needs.

Staffing

Although midwives continued to undertake scrub duties in obstetric theatre, this only occurred when they picked up additional bank shifts to cover rota gaps within the surgical care group.

Midwives had completed Practical Obstetric Multi‑Professional Training, Care in Pregnancy and the Postnatal Period, Maternal Acute Illness Management and Enhanced Maternal Care; however, these did not provide the formal peri‑operative competencies required for scrub or recovery practice.

Midwives rostered for maternity services did not carry out the scrub function as part of their maternity shift, as the surgical care group operated a separate rota and staffing model.

Leaders acknowledged this arrangement was not aligned with national peri‑operative staffing guidance but continued to use midwives in this way during periods of staffing pressure.

This meant midwives were undertaking tasks outside the expected peri‑operative competency framework, creating ongoing risks related to delays, errors and reduced resilience during theatre activity.

Leaders planned to address these risks through the introduction of a new post anaesthetic care unit due to be opened in June 2026 along with a revised staffing model separating theatre and recovery teams, and the appointment of a dedicated recovery nurse. A new standard operating procedure had been developed to support this transition and reduce reliance on midwives undertaking dual roles.

The service remained non-compliant with Safety Action 4 of the Saving Babies Lives Care Bundle. Birth Rate Plus across both sites identified a gap of 44 whole time equivalent clinical midwifery posts and additional roles within the maternity quality and safety team. The trust board approved a three year plan to increase staffing, including increasing workforce headroom to 24% and uplifting community and triage staffing. The service had a high number of band 5 midwives who remained supernumerary and were supported through structured development, and this cohort would move into the staffing provision once they completed their supported practice period. It will take time to implement the full workforce uplift.

Triage staffing was not consistently safe. The service relied on only one midwife and one midwifery support worker to staff triage most evenings, which created a heavy dependence on both staff being available to work. During night time periods, this level of staffing was not always achievable, and the triage service was relocated to the labour ward to maintain safety and oversight. The triage line relocated overnight to York to ensure safe call handling. There were no associated incidents of moderate harm or above reported. Senior leaders informed us that additional funding had been secured to ensure two midwives were on duty at all times and to strengthen telephone triage. They also identified the need for a dedicated lead consultant for triage to support consistent clinical oversight and standardised decision making.

Staffing pressures were evident amongst maternity support workers (MSW’s) and maternity assistants. Fill rates varied from 43% to 100%, creating inconsistent cover in some areas. There was an 8% vacancy rate, 10% turnover and 14% sickness. Administrative staffing showed similar pressures with an 8% vacancy rate, 11% turnover and 7% sickness.

Midwifery staffing had strengthened. Safe and effective staffing processes were consistently in place, with sufficient staff in post and reduced sickness since the previous inspection. Reliance on agency staff was minimal, and midwifery fill rates were consistently above 90%, although antenatal services were lower at 76%. Women told us there were enough staff available to meet their individual needs.

There was reliable oversight to ensure safe staffing levels. Handovers included discussion of staffing and patient acuity, and the midwife coordinator had oversight of all clinical areas to support safe deployment of staff. An acuity tool was used every four hours to assess workload and inform staffing decisions. Matrons held daily responsibility for safe staffing, supported by cross site huddles and a robust OPEL scoring system.

The birth to midwife ratio was monitored effectively. It was calculated monthly using Birth Rate Plus, and the live acuity tool supported real time staffing decisions.

The service consistently achieved 100% compliance with the ratio of one midwife to one woman in established labour.

The service had a consistent cohort of trained agency midwives to support continuity.

Staff were positive about the new estate plans and the staffing uplift. They felt these changes would support safer and more sustainable care.

Medical staffing had strengthened. Establishments were full, turnover was minimal and sickness had reduced. Consultant staffing remained stable, rotas were compliant and consultants provided cross-site cover for clinics and theatres.

Resident doctor staffing was stable overall. Sickness and vacancy rates varied by tier, but were balanced operationally, and no temporary bank staff were used. A trust wide resident doctor workforce review was completed in March 2026 however no additional posts had been allocated to maternity.

Strengthened medical staffing, reduced reliance on locums and improved midwifery staffing increased stability across clinical areas. This meant the service was no longer in breach of Regulation 18 – Staffing, in relation to ensuring there were enough midwifery and medical doctors to meet minimum staffing levels.

Training

Mandatory training compliance did not consistently meet the trust’s 90% target. Higher level Mental Capacity Act and Deprivation of Liberty Safeguards training was 60%, with compliance rates of 44% for consultants, 33% for lower tier resident doctors and 31% for band 5 midwives. Other lower performing subjects included adult resuscitation at 50% for band 5 midwives, conflict resolution at 50% for band 5 midwives, infection prevention level 2 at 55% for resident doctors and information governance at 55% for resident doctors across higher and lower tiers.

Therefore, the service remained in breach of Regulation 12 - Safe Care and Treatment, as staff were not consistently maintaining essential clinical competencies in line with safe practice expectations.

Non-compliance was concentrated within a small number of teams and roles. This included new starter midwives who joined in February and March 2026, rotational resident doctors and specific wards with localised dips.

Compliance with mandatory training on learning disability and autism remained below target at 74% for part 1 with part 2 still being rolled out.

Training access had improved. Training was rostered into timetables and staff reported good access. Strong performance was achieved in infection prevention and control, safeguarding adults, safeguarding children levels 1 and 2, preventing radicalisation, needlestick safety, medical gas safety, fire safety awareness, and sepsis awareness.

Midwifery emergency training had strengthened. All midwives were now compliant with practical obstetric multi professional training (PROMPT) and fetal monitoring training. Training days incorporated real life case scenarios to support learning and reflection.

Improvement plans included a skills passport dashboard and a three year training needs analysis.

Appraisal compliance remained below the trust’s 95% target. Managers delivered appraisals and supported staff development, and matrons described ongoing maternity culture work and were proud of how staff supported each other. However, appraisal rates at 78% for midwifery staff and medical staffing at 80% which remained below the required standard. These had improved significantly from the last inspection when compliance was 15% for midwifery staff and 42% for midwifery care assistants. These shortfalls indicated areas for improvement and meant the service remained in breach of Regulation 18 - Staffing. This meant staff did not always have the opportunity to discuss ongoing training needs in order to develop their skills and knowledge.

Senior leaders told us they had removed the appraisal window and moved to anniversary based appraisals so staff could schedule appraisals across the full financial year. This enabled greater flexibility, more meaningful and timely development discussions, and stronger alignment with personal development planning, reflecting feedback from staff surveys.

The service met Maternity Incentive Scheme Year 7 Safety Action 8 by delivering local training plans and providing in house multi-professional training aligned to Saving Babies’ Lives Version 2.

Community midwives accessed regular refresher sessions to maintain confidence in supporting home births.

Agency staff were required to complete a maternity skills passport before undertaking shifts.

Clinical educators provided ongoing support and oversight of training and competence. Staff reported positive induction experiences.

Newly qualified midwives described a supportive preceptorship period with supernumerary time.

Resident doctors were supported through peer learning, weekly teaching, and educational meetings.

The service demonstrated a consistently good standard of infection prevention and control (IPC). Staff assessed and managed infection risks effectively and took prompt action to prevent the spread of infection.

Cleanliness across maternity areas was high, with most areas achieving four to five star ratings. Women consistently described the environment as “high standard,” “clean” and “presentable.” Cleaning records were up to date and showed that ward areas were cleaned regularly.

Staff cleaned equipment after use, labelled it appropriately and stored it correctly. Equipment was stored off the floor, and sterile areas, including maternity theatres and delivery rooms, were well-maintained. Handwashing facilities and hand sanitising gel were readily available in all areas visited, with clear signage promoting effective hand hygiene. Staff adhered to infection prevention principles, including appropriate use of personal protective equipment, maintaining bare arms below the elbows, regular handwashing, and compliance with the trust uniform policy.

Senior leaders met regularly with the IPC multidisciplinary teams, who attended wards and contributed to oversight and improvement. Monthly hand hygiene audits showed compliance ranging between 80% and 100%, providing variable, but ongoing assurance around hand hygiene standards. Clinical and non-clinical waste was managed appropriately, and staff disposed of sharps correctly in labelled sharps bins.

There was no longer a dedicated maternity theatre infection prevention and control oversight group in place, with governance now managed through the wider surgery care group IPC structure.

There were delays to the newborn vaccination of the bacillus calmette guerin vaccine (BCG), which is essential to prevent avoidable infection risk from tuberculosis, with 0% uptake within 28 days for babies born in February 2026. This had been escalated and a clinic was arranged for April 2026, with staffing cover issues added to the risk register and additional oversight provided through a new task and finish group.

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

Although staff had made progress in strengthening medicines processes, the audit data showed that key risks in prescribing, administering, documentation and the safe and secure handling of medicines remained.

Audit data identified some concerns about the safe and secure handling of medicines from incidents, controlled drug inspections, and discussions with staff. These included underuse of midwife exemptions on electronic prescribing and medicines administration system, discharge medicines being issued without a prescription, inconsistent adherence to medicines administration processes, gaps in controlled drug documentation and weekly checks, and variable compliance with safe storage standards.

An audit of Entonox prescribing and administration over 12 months showed a significant gap between the number of women receiving Entonox and the number of occasions it was prescribed or recorded under a midwife exemption. This indicated low compliance with required prescribing and documentation.

Targeted reviews of take home medicines identified variation in prescribing accuracy. On the labour ward, compliance with inpatient and discharge prescribing of Enoxaparin 60 mg injections was 80% in March 2026, but in both cases the TTO pack issued contained the incorrect strength. On the antenatal and postnatal ward, compliance with inpatient prescribing of Cefalexin 500 mg capsules was 80%, while discharge prescribing compliance was lower at 50%. This showed ongoing variation in prescribing accuracy and discharge medicines processes.

A missed critical medication dose audit for March 2026 showed missed dose rates of 12% on the delivery unit and 16% on the antenatal and postnatal ward. Missed doses can cause serious harm and impact outcomes, emotional wellbeing, and length of stay.

The trust had commenced a 12 month programme of improvement work in January 2026, including monthly teaching sessions and quarterly audits.

There had been improvements since the last inspection. Positive practice was identified with ward assurance results showed compliance with daily medicines fridge temperature checks, and medicines storage had improved across maternity areas.

Medicines were stored safely, securely and were well organised with March 2026, compliance evidencing safe storage standards rate of 86%, and safe and secure handling assessments were 82%.

Controlled drugs were stored appropriately with restricted access, accurate record keeping and a clear process for reporting any discrepancies. The trust used an electronic system to prescribe and record the administration of medicines.

Community midwives transported Entonox securely in designated pool cars, ensuring safe access to analgesia during home births.

Care records showed that staff consistently discussed and recorded women’s current medications, vitamins, and supplements at each antenatal appointment, ensuring accurate and up to date information to support safe care.

Staff were involved in a quality improvement project to strengthen medicines management in response to the CQC maternity survey 2025 results. Actions focused on enhancing analgesia options, improving medication round processes, and exploring self-administration.

Senior leaders confirmed a business case had been approved to appoint a designated maternity pharmacy technician. To mitigate this gap whilst recruitment occurred, there was a daily pharmacy presence for two hours, alongside ongoing medicines optimisation audits and collaboration with the lead nurse for pharmacy.

Whilst there were still gaps identified in medicines optimisation, the service was aware of these, were undertaking regular audits, reporting the findings, and actioning improvement. This meant the service had resolved the breach of Regulation 12 - Safe care and treatment.