Harrogate District 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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has improved to good.

Good: This meant people were safe and mostly protected from avoidable harm. However, we observed some areas which required further development as there was an increased risk that people could be harmed as deterioration and risk processes were not always completed and documented and shortfalls were observed in oversight of time to medical staff review.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Information on listening, duty of candour and incidents was displayed on the Delivery suite for staff and families to see. Policy information was also available for staff to access.

The trust confirmed 629 incidents, of which 518 were patient related incidents from July 2024 to July 2025. Highest levels of incidents related to post-partum haemorrhage over 1500ml (53), incorrect treatment (47) and 3rd and 4th degree perineal tears (32); of which 3 were classified as medium harm incidents. Most events were on the Delivery suite (322), followed by Pannal ward (142). No never events or patient safety incident investigations (PSIIs – formally Serious Incidents) were identified within this period.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if things went wrong. All staff knew what incidents to report and how to report them. Staff said immediate multi-disciplinary team debriefs took place following adverse events. The debrief was followed by a formal review and learning was identified. From the 30/7/24 to the 30/7/25 the trust confirmed all 3 duty of candour cases investigations were completed within 10 working days. Leaders said these were always discussed at the review of serious events Rapid Review of Serious Event (RROSE) panel and with the team.

Staff said learning was shared as part of the incident process, through the maternity risk management group meeting minutes, attendance at and feedback from perinatal mortality review meetings, at safeguarding supervision sessions, and via emails and newsletters. Staff said changes resulted following feedback. In the Antenatal clinic learning from incidents was in an incident proforma file, which was signed by the midwives and support workers when they had read it.

In summary the trust PSIRF (2025-2026) plan document identified some context; the list of current priorities associated with the PSIRF framework and how the process focused on learning and continuous improvement. The PSIRF plan was supported by a standard operating procedure, the Local Maternity and Neonatal System Maternity Patient Safety Incident Investigation (PSII) process and the Patient Safety Incident Response Policy. Support for PSII investigations was provided by the trust wide lead investigator and 3 patient safety specialists.

The Associate Director of Midwifery reported summaries of incident type information to the board. Actions and learning points were shared with team leaders and Delivery suite coordinators who ensured they were disseminated through the service. The electronic maternity newsletter hosted on a system called ‘Padlet’ shared information and learning from a wide range of topics which included incidents and events.

Leaders said that when patient safety investigations (PSI) took place the investigation was managed by an external party. Leaders said they were assured by the PSIRF framework as a maternity PSIRF plan was in place; national reporting was as previously which meant thematic reviews could take place. The trust had completed thematic reviews on retained swabs and recently on deteriorating patients for which the report was being completed.

We tracked one patient safety incident and saw the incident was documented, reviewed and reported. The incident met the rapid review criteria and the 48 hour document completed. Documentation confirmed meeting attendees and the initial email meeting attendance proforma. Learning from the incident was shared by email to the team and at the Planned and Surgical and Children's Care directorate meeting on the 7 June 2025. The meeting minutes and updated report and immediate actions were shared with the multi-disciplinary team on 11 June 2025.

The maternity risk management newsletter (June 2025) confirmed the findings and recommendations from 13 patient safety incident investigations (PSII) to inform staff and practice. These also included a summary of areas for improvement and safety actions.

We were told staff had not received training in the use of the patient safety incident response framework (PSIRF) but had received introductory information produced by another NHS body for this area.

The service used a review of serious events Rapid Review of Serious Event (RROSE) panel to review high-risk patient safety incidents. The progress and learning from these incidents were discussed at the maternity risk management meeting. The panel determined if the incident met serious incident status. Leaders were proud of this process and how the multi-disciplinary team teams were involved in the process. Leaders described a no blame approach which focused on learning.

The maternity and newborn safety investigations (MNSI) national and regional data (1 April 2019 – 7 May 2025) confirmed 8 of 14 referrals were progressed to investigation of which all were completed. Learning had resulted from the investigations.

Maternity and newborn safety investigations (MNSI) meetings took place quarterly. Individual MNSI were tracked by the MNSI link person to the trust. Staff said there had been one MNSI notifiable case in 2025 which was currently being investigated by MNSI. No MNSI notifications were received in 2024. The service shared the MNSI quarterly report dated 10 October 2023 which identified actions following investigations. The service shared the MNSI quarterly report dated 10 October 2023 which identified actions following investigations. An action log was identified which did not include the actions identified within the recommendations. Since the assessment the trust provided the action plan dated 29 August 2023 which confirmed most actions identified were completed and learning from this event shared in the October 2023 Risk Management newsletter.

The service provided monthly audit data on the 13-watch metrics (August 2024 – June 2025). This data included monitoring of stillbirths and neonatal deaths (NND) whose threshold was identified as >0. During this period, there had been 1 to 2 stillbirths and / or NND over a 5-month period; 5 were identified from February to May 2025. Nationally mandated processes such as PMRT/rapid review and MNSI were used in the management of perinatal death, and we saw shared learning identified from case based thematic reviews which were shared on PowerPoint presentations.

We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The service’s referral, transfer and admission processes ensured that essential information about the women was received to determine if the women’s needs could safely be met. Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. Transfer of care maternity specific guidance advised staff on several scenarios. We had asked for a copy of the trusts latest transfer agreement as evidence, this was not provided.

The community staff followed a continuity model for antenatal care. The integrated model meant some midwives rotated into Delivery suite.

The 2022 CQC report had identified no clear system in place to identify and prioritise risks to women in the maternity assessment area. Since the 2022 assessment the maternity service had implemented a triage system. Triage guidance was available for staff to access via the maternity assessment guideline (v1) and triage guidance displayed in the maternity assessment centre (MAC) and Delivery suite for staff information.

The 4-bedded MAC operated 7 days / week from 07.30 am – 8 pm. Outside of these times people requiring assessment were advised to attend the Delivery Suite. Since the CQC assessment the trust planned to increase MAC opening times from December 2025 to remain open until midnight. Women attended the MAC for the assessment of complications of pregnancy from 13 weeks 6 days onward. A designated telephone number was available as a single point of contact which women could access should they require advice or support.

The MAC operated a red, orange, yellow, green (ROYG) rating system to prioritise the order in which women received care by the midwives and medical team. We observed this rating system for when women were seen, for example a red rating was to see immediately on Delivery suite, followed by amber to see within 30 minutes.

There was no oversight of time to medic review in the MAC to inform obstetric staffing. Staff said they would contact a medic when they were needed. Timeliness of women’s medical reviews were not recorded in the MAC risk rating log. This meant that the service could be breaching its ROYG protocol if women were not seen within the timescales identified. During the assessment we were told that waiting for doctors was a concern and we saw evidence of long waits experienced by one woman.

Staff provided advice either over the phone or at the MAC. Monitoring of call times to the MAC was by length of time; the call was transferred to the Delivery suite if not answered within 1 minute. Calls to the service were recorded and confirmed women were initially triaged and advised accordingly.

During increased activity, the midwife would be unable to maintain activity timescales if they were multi-tasking their workloads, such as answering the phone, triaging women face to face and the completion of planned activity. Women from the MAC were moved to the Delivery suite by 8 pm. Staff from the Delivery suite said women due to give birth were prioritized ahead of those women who had moved across from the MAC. This meant newly admitted women to the MAC initial triage may not take place within 15 minutes of arrival to the unit.

Staff said women were not re-assessed once they attended MAC. Women were taken in for observations and fetal monitoring, however, if the midwife was busy, there was an inbuilt delay which was not audited. Staff said the initial triage of the women took place within 15 minutes of arrival.

The trust confirmed triage times compliance was monitored and when not achieved staff would report this as an incident. Over the last 12-months there were 9 occasions when breaches were noted when women were not seen within the 15-minute timescale. In context, the MAC had 350 - 400 attendances on average per month. The service had created an action plan of 19 actions of which 17 were complete. This action plan was bench marked against the Royal College of Obstetricians and Gynaecologists (RCOG) Maternity Triage Good Practice Paper No 17 (2023)

We looked at the risk scores assigned to women on arrival to MAC. Records of risk scoring in the ward returns folder of women were completed whilst they were in the MAC. We observed that risk scores were not transferred to the women’s health records. Recording of the triage risk rating was seen to be incomplete and inconsistent on Badger net, the electronic recording system used in maternity. We reviewed 17 women’s records from the MAC and noted that 6 records only had risk ratings identified. Following the assessment the trust informed us they had raised this as an issue with the system supplier on several occasions and it has been recognised as a National issue.

We reviewed retrospective records of women transferred to the Delivery suite to be monitored; risk scoring had not taken place. We raised this with the senior leadership team as a risk as part of our final high-level handover.

Out-of-hour escalation processes were supported by an on-call midwife overnight.

The central alerting system (CAS) issued patient safety alerts which were followed up by the trust quality team. Staff said alerts were tracked via the trust corporate team and maternity specific alerts were responded to by an identified staff member within maternity.

We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

We scored the service as 2. There were some shortfalls in the completion of safeguarding training. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives, while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Safeguarding governance processes and leadership was in place. The Executive Director of Nursing Midwifery and Allied Health Professionals was the Executive Board Lead for Safeguarding, Children in Care and Learning Disability and Autism. The annual safeguarding report (July 2023 – July 2024) was presented to the trust board by the responsible director on the 25 September 2024.

The named midwife represented maternity services at partnership quarterly meetings. The named midwife worked closely with other named midwives in region. Safeguarding meetings included attendance by multi-disciplinary teams across North Yorkshire and Cumbria. Subjects discussed included: safeguarding incidents, policy updates, training and information sharing.

Staff knew who the safeguarding midwife was and said that they offered good support, described her as accessible and could run a problem by her as needed.

The safeguarding lead ran quarterly safeguarding supervision for community midwives and biannually for trust midwives. Leaders said community midwives had caseload supervision sessions.

The 2022 CQC report had identified shortfalls in staff attendance at safeguarding training sessions. At this assessment, the training target was 90%; medical staff training compliance for L2 adults safeguarding training remained at 73%, whilst compliance had decreased to 54% from 55% in 2022 for L3 children’s safeguarding training. Preventing radicalisation training was completed by 69% of medical staff.

Improvements were noted in midwives safeguarding adults and children level 3 training compliance levels; compliance was at L3 adults (87%) and L3 children (98%) respectively. Midwifery managers and nurse managers had competed L3 training in adults and children’s safeguarding, whilst one midwife had completed level 4 – Children’s Safeguarding training. All midwifery staff had completed the preventing radicalisation training.

Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS), adult and children’s safeguarding training, domestic abuse, honor-based abuse and modern-day slavery training were available for staff. Staff were guided on how to complete the domestic abuse, stalking and honor- based violence (DASH) assessment tool. We observed shortfalls in training compliance for medical and midwifery staff in Mental Capacity Act – L2 (73% - midwives, 67% - medical staff), Mental Capacity Act including Deprivation of Liberty awareness identified 2 medical staff to complete, to date one medical staff member had completed this training. The safeguarding midwife wrote to individuals if they were not compliant. New starters had 16 hours of safeguarding training as soon as possible, within the first 8 weeks.

Safeguarding referrals went through Badger net and were discussed at the weekly team meeting to hand over any risks and concerns. Feedback was also given to staff through supervision processes. There had been safeguarding referrals made as appropriate over the last 12 months.

We reviewed two women’s notes on Badger net and noted coloured flags identified whether they required mental health or safeguarding support. Safeguarding is a yellow flag on the system and mental health is a purple flag. For one woman we saw the safeguarding concerns recorded and a plan in place to ensure immediate family safety.

Staff said where a young person was under 16 years of age safeguarding risk assessments were completed in the community and a referral to the safeguarding team completed. If the young person was on a child protection plan a pre-planning meeting, took place.

The Named Midwife for Safeguarding, Perinatal Mental Health and Vulnerabilities Lead Midwife worked with the Perinatal Mental Health Midwife. They had built-in modern-day slavery and included this in the training. Staff were encouraged to be professionally curious. The perinatal mental health midwife supported mothers with mental health issues and signposted to mental health services for additional support.

The perinatal mental health (PNMH) 2024 safeguarding action plan identified 10 actions, one of which was complete. The action plan identified actions such as safeguarding supervision, PNMH guidelines and referral processes, use of baseline assessment PNMH tools at antenatal and post-natal stages. Target dates ranged from 30 September – 31 December 2025 and evidence towards progress made was identified for each action.

The safeguarding team undertook audits to monitor domestic abuse, perinatal mental health and any incidents reported.

We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

We scored the service as 2. The evidence showed some shortfalls in training and how the service monitored and recorded potential areas of risk. 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 said the situation, background, assessment and recommendation (SBAR) audits were last completed in November 2023. The SBAR audit frequency had not been identified. Compliance was identified as 79% and 82% for the intrapartum period. To-date one SBAR audit had been completed.

Staff said a Maternity Assessment Centre (MAC) audit was planned but had not progressed. Telephone triage audit was not included within the MAC audit plans.

Staff could access specific policies, guidelines and escalation pathways which advised on the deteriorating patient and septic patient. Deterioration was monitored through recognised tools such as the Modified Early Obstetric Warning Score (MEOWS), and Newborn Early Warning Trigger and Track (NEWTT). In 10 records we saw some gaps in the documentation of MEOWS and NEWTTS for babies being completed and escalated.

The MEOWS was recorded on the electronic hospital wide PatienTrack system, but we were unable to review archived PatienTrack records from the previous week, this was escalated to senior staff. PatienTrack is a separate electronic system to the electronic Badgernet system used within the maternity service. Following this escalation, we were told that MEOWS had not been recorded as MEOWS was not recorded on PatienTrack during labour and is recorded on Badgernet to enable plotting on the partogram. We reviewed one resident woman’s electronic record and saw the electronic MEOWS charts in use. Early warning scores were recorded on the general observation chart and showed no need for escalation.

Staff said when women’s scores deteriorated medical staff were alerted immediately by the PatienTrack system. Midwives bleeped the doctors with any concerns. We reviewed 10 additional women’s records and noted an inconsistent approach to recording MEOWS; we were also not able to identify the recording of babies NEWTT readings within the charts. NEWTT was not recorded clearly on Badgernet. We observed clinical observations were completed but were not scored to give an overall MEOWS score. The service needed to embed the use of the tools used to monitor deterioration so they could be assured women’s and babies status were being monitored and escalated appropriately. We did not see evidence these tools were monitored as part of the services quality framework.

Staff said NEWTT2 had not been implemented and there were plans for training and guideline development and electronic recording in this area. This area has not been fully developed yet as the associated electronic web was not in place. Following the assessment the trust confirmed they had been involved in piloting NEWTT2 in System C (Badgernet) and plans were in place to roll out NEWTT2 as part of the Nervecentre electronic patient record implementation in November 2025.

Five of the 10 women’s records reviewed confirmed the domestic abuse question was not asked.

The service audited surgical site infections (SSI’s) following caesarean sections. This audit was conducted to review SSI cases among 23 women who underwent caesarean sections between September 2024 and March 2025, of which 17 women developed an SSI. The report states that of all patients who had a caesarean section (total = 410) between 1 September 2024 and 19 March 2025, 23 patients were identified to have a suspected or confirmed surgical site infection. Of these 23, 17 had a confirmed surgical site infection. A re-audit was planned for December 2025. The action plan identified 3 actions; the one which was completed related to clearer documentation of infections.

The service completed an audit on missed sepsis assessment (December 2024 – February 2025). The outcome of the audit confirmed no actions were required as all patients had been assessed and escalated as required.

We observed the use of the NHS surgical safety checklist in theatre to ensure patient safety during a caesarean section. The theatre checklist tool used to capture the information confirmed all but 5 areas were completed. During the procedure we observed the documentation of needles and swabs were not consistently recorded. We also reviewed 10 additional patient records to ascertain whether swab counts were completed. We saw gaps in 7 records pertaining to completion of swab counts. This could potentially pose as a risk should all equipment not be accounted for prior to the woman’s surgery being completed.

The trust audited compliance against surgical safety checklists completed in the Delivery suite theatre over a 6-month period. Compliance was 100% for 337 cases. The trust was currently undertaking further actions over the next 6 months to scrutinise the data further as part of the Eight Steps to Safer Surgery project.

Induction of labour (IOL) information was monitored by the trust through its watch metrics and progress reported within strengthening maternity and neonatal safety reports. IOL was also identified as one of the 12 existing active risks on the risk register. This risk scored a 6 and related to patient satisfaction and safety, resulting from delays in facilitating IOL. The watch metrics confirmed the percentage and number of women being induced; the threshold was 40%. From August 2024 to June 2025 this activity ranged from 27.3% (41 women) to 32.9% (49 women). The June 2025 strengthening maternity and neonatal safety report confirmed in June 2025 there were 11 delays in induction of labour of over 24 hours. The June report confirmed from July 2024 to June 2025 there were approximately 8-13 delayed IOL cases on Pannal ward and appropriate actions were taken to manage the situation. The detail of these actions was not identified. An annual re-audit of IOL was due in 2024; however, confirmation this had been completed was not provided.

Staff involved people to manage risk through communication, so they understood their care and treatment. They also found ways to communicate with women with communication difficulties.

Staff ensured that patients could access advocacy and enabled patients to give feedback on the service they received (for example, via surveys or community meetings).

We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Entry to the maternity clinical areas was secure and could be accessed by staff by their own swipe card. Visitors access was monitored through a camera / bell access control panel.

Throughout the maternity service we observed the environment to be mostly well maintained. On Pannal ward some vinyl seats showed wear and tear with cracked and worn seating. In the antenatal clinic some chairs had fabric as part of their build which looked worn.

Antenatal clinic areas were clean and tidy, and equipment was tested and serviced. Some examination couches in the antenatal clinic were high and fixed in position which could constitute a risk and limit accessibility if used. Staff said the examination couches were not used. One electric adjustable examination couch was seen in the antenatal clinic.

The early pregnancy assessment unit (EPAU) waiting room was small and situated in a remote corridor on the ground floor. There was a back way to the waiting room to promote privacy and dignity. The EPAU accommodated 6 chairs and was windowless. A quiet room also duplicated as an office, staff kitchen and for notes storage.

The emergency call bell in EPAU did not work. This was known to the hospital, and they were waiting for works to take place.

We checked random pieces of equipment throughout the service and found most had either been safety tested or had service stickers on. However, in the triage unit, we noted that beds 2 and 3 had no service stickers on to confirm the date of their last service/check. We asked staff whether the beds had been recently serviced and were told that they had been 2 weeks previously. We did not see written confirmation of these checks whilst onsite. Two thermometers in the triage area were seen to be due servicing as their test stickers identified services were due; dates identified as the 16 and 18 June 2025 respectively.

Service maintenance records confirmed 6 pieces of equipment were overdue a service. The maintenance records confirmed 143 pieces of equipment as in-date, whilst 114 pieces of equipment had planned maintenance due from June to August 2025.

Staff training records confirmed compliance levels with equipment training requirements. The report was compiled on the 29 July 2025 and confirmed equipment training compliance ranged from 73% to 85%. Additional training records dated 1 April 2024 – 31 March 2025 confirmed midwives’ completion of equipment training. However, from this information we could not determine whether all midwives had completed the relevant equipment training for their roles.

On Delivery suite the staff room (room E2089) fire door was propped open with a bin.

One resuscitation trolley served three clinical areas, the Delivery suite, the Maternity Assessment Centre and Pannal ward. We asked the midwife whether the presence of one resuscitation trolley for the 3 clinical areas had been risk assessed and they said they were not aware of a risk assessment. The Trust provided the hospital wide risk assessment for risk categorisation of areas and associated resuscitation equipment provision.  This was identified as an evolving document which was reviewed annually. Senior staff confirmed this risk assessment had recently been updated to include what portable monitoring equipment should be available or taken to calls outside of clinical areas. The document remained in progress due to the ongoing reviews.

A medical gas cylinder storage and use in clinical areas risk assessment was completed on the 28/11/23 and was due for review. Two risk assessments were provided one for Pannal ward, the other was for outpatients and community. We could not be assured that the risk assessments action was completed as the action plans did not confirm completion of the actions. Leaders said Entonox: eLearning was live on Learning Lab to support clinical staff in the safe use and storage of Entonox.

Leaders said a new control of substances hazardous to health (COSHH) steering group was established in January 2025; the risks associated with Entonox would be monitored through the new COSHH risk assessment. To support this implementation leaders said internal training to complete these had just been developed to ensure staff were competent to complete these.

The COSSH policy (June 2025) and Safe Handling and Disposal of Flammable and Oxidising Products policies were launched in January 2025. A revised procedure for requesting use of Entonox in a new clinical area was in development and the health surveillance policy was in draft with Occupational Health.

Leaders said ligature risks were considered within the service where new refurbishment works had or were about to take place so that areas were ligature light. Environmental risk assessments were carried out on Pannal ward and Delivery suite on the 16 July 2025. This assessment was in draft and was undergoing review before being finalised. Leaders said the assessments would be monitored and reviewed no later than one year.

Staff said they had two obstetric portable ultrasound machines on the Delivery suite. A competency package was launched for midwives to be able to scan for fetal presentation before induction of labour or where a non-cephalic presentation is suspected. Midwife coordinators and some band 6 and 7 midwives had completed the training. Midwives had worked alongside an obstetrician initially until their competencies were signed off.

Breastmilk storage fridges were in ward areas, and we observed milk samples clearly labelled. Processes were in place for milk which was not used and who to contact. Breast pumps were free to those women with a clinical need, otherwise a charge was in place.

On Pannal ward the microwave oven appeared rusted with evidence of food stuffs from previous use. Staff said this microwave was condemned following an environmental health assessment but continued to use it. The microwave was escalated to senior staff once discovered however it was still there the next day.

Staff said there was a lack of blood pressure (BP) and CTG equipment on Pannal Ward. We asked senior staff about the lack of BP equipment and were told there were 4 BP monitors available for staff to use. Two BP monitors were present in the Maternity assessment centre and would be used by Pannal ward staff at night.

We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

We scored the service as 2. The evidence showed some shortfalls in midwifery staffing levels which meant the service did not always have enough qualified, skilled and experienced staff. The service training target of 90% continued not to be achieved in most training categories, although some areas had improved. Staff had effective supervision and improvements in appraisal compliance were achieved. Staff worked together well to provide safe care that met people’s individual needs.

Staffing and Acuity

Birthrate Plus is the recommended decision support tool for assessing and determining midwifery staffing levels and is used in conjunction with professional judgement to calculate the workforce required to deliver safe maternity services. The strengthening maternity and neonatal safety report for June 2025 confirmed the Birthrate plus establishment setting review was completed in August 2024 and will be repeated in 2027. The establishment review resulted in an increase in staffing levels for the service.

The maternity risk register identified a risk score of 8 in relation to the risk to patient experience and breach of triage timescales due to insufficient midwifery staffing in the Maternity Assessment Centre (MAC). Midwifery and medical staffing establishments were monitored closely through committees which reported to the trust board. Staffing reports were completed by ward managers monthly and a 6-monthly staffing report and business plan were presented at the trust board. The latest 6-month staffing report dated 1 October 2024 to 31 March 2025 provided assurance to the trust board of an effective system of midwifery workforce planning and monitoring of safe staffing levels in the maternity department. This was a requirement of the NHS Resolution Maternity Incentive Scheme, Safety Action 5. The report concluded with 2 recommendations; progress against one was made as the service was going to recruit band 7 midwives. Minutes of the maternity and neonatal safety champions group (dated 9 June 2025) board papers section confirmed the bi-annual staffing report and a business case to support staffing was underway.

Business proposals in April and June 2025 respectively identified an uplift in midwifery staffing by a total of 5.48 wte Band 7 midwives and maternity support workers by 5.58 wte, ward clerks by 0.5 wte and the addition of a Head of Midwifery at Band 8b, 0.6 wte. Following the assessment, we received confirmation the maternity business case for a staffing proposal which related to an uplift in band 7 midwives by 5.48% was agreed on the 23 April 2025. Confirmation was noted in the 18 June 2025 strategy deployment room minutes that 1.6 w.t.e. band 7 delivery suite coordinator and 1.92 w.t.e band 6 midwife had been recruited.

Staffing shortfalls were replaced by either by permanent staff or NHS Professionals (NHSP) who knew the maternity unit. Some staff said they had worked additional hours to support staffing shortfalls. Delivery suite and MAC rotas dated from 2 June - 23 July 2025 confirmed the shifts NHSP staff had worked were mainly day shifts; NHSP staff were employed to fill 21 shifts in June 2025.

Planned vs Actual Staffing:

Leaders shared the planned vs actual maternity staffing for 2025-26 which confirmed trained maternity staffing levels. Funded staffing was 82.29 wte; Total number of staff in post – 85.97 wte. of this 7.97 wte. staff were on maternity leave which was reflected in the reduced in post statistics of 78 wte. The May and June 2025 day and night fill rates for midwives and support workers information confirmed trained staffing appeared sufficient at night, with an increased need for NHSP staff during the day.

The June 2025 rota confirmed band 7 cover was present on the delivery suite 24/7. The band 7 midwife also provided support to staff on Pannal ward. Maternity assessment centre (MAC) rotas were managed through the delivery suite midwife coordinator who ensured a band 6 midwife was allocated to the MAC with a maternity support worker supporting them. The antenatal clinic manager worked clinically to cover staffing shortfalls; staff were redeployed from other areas to cover the clinic; they were expecting staff to return from leave very soon.  Staffing within the early pregnancy assessment unit included a band 7 nurse sonographer who had access to the lead sonographer for clinical supervision.

Staffing Escalation/ Forum meetings:

Monday weekly huddles with team leaders discussed staffing requirements for the week. The manager of the day supported the service, whose role included the review of staffing requirements. Daily sitrep meetings took place at 10am. Leaders reviewed staffing levels in the morning, at midday and in the afternoon if escalation took place when busy. On-call managers were contactable at night for advice and support. In addition, community on-call midwives were first and second on-call.

Delivery suite forum minutes for May and June 2025 confirmed attendance by the multidisciplinary team. Discussions included areas such as incidents, guidelines, audit and quality improvement, action points and shared learning.

Midwife to birth ratio:

To provide a safe maternity service, the Royal College of Midwives (RCM) identified an average midwife to birth ratio of one midwife for every 28 births. At this inspection midwife to birth ratio compliance documented in the June 2025 strengthening maternity and neonatal report confirmed 1:1 care compliance ranged from 99.2 – 100% from July 2024 – June 2025. Prior to this the Harrogate Maternity Services Overview document confirmed the 1:1 rate from January 2024 to December 2024 was 99.6%.

Specialist midwives: In total 11.56 wte. specialist midwives at bands 6, 7 and 8a supported the service.

Community Midwives:

Community midwives supported home births. The June 2025 strengthening maternity and neonatal report (the report) confirmed 8 am – 6 pm (long) ten-hour shifts were removed. These were replaced with 9 am – 5 pm eight-hour shifts to enable more effective use of midwifery hours over the course of the week. 8 midwives worked from 8 am 6 pm (47%) and other midwives worked from 8 am – 6 pm on their clinic day. Caseloads were 1 midwife to 74 women (1:74) which was in line with National Institute for Health and Care Excellence guidance of 96 cases per wte. midwife. First and second on call community midwife systems were in place. The report confirmed home birth on call provision was unavailable from 1 June – 30 June 2025 on 5 occasions due to no volunteers to cover. Community midwives’ skills development was enhanced for some when they worked in the maternity inpatient unit; all community midwives had completed Practical Obstetric Multi-Professional training (PROMPT).

Staff feedback on staffing:

We received mixed feedback on safe staffing within the service, some staff said they were understaffed, whilst other staff said day shifts were safely staffed. Staff said on occasion the specialist midwives and midwifery managers worked clinically to support the service when the acuity tool birthrate plus indicated midwife shortages.

Staff said on occasion they were redeployed to other areas when staffing was low and acuity high. Some staff said it had been stressful when they were redeployed to the Maternity Assessment Centre (MAC) as there was only one midwife and 1 maternity support worker to do everything. Workload included day unit appointments, face to face triage, monitoring of women in the triage area and telephone triage services. Staff from the MAC said they did not always do everything on time, did not have breaks and had not recorded this as an incident due to being too busy. Following the 2023 - 2024 staff survey staff were encouraged to take breaks during their shifts. Staff said they felt it was unsafe working in the MAC and commented that other staff did not like working there. From 8 pm telephone triage was completed by any midwife. Staff said this was risky because if you were caring for other women, you may not concentrate fully on the telephone triage.

Maternity Statistics:

Midwifery vacancies were 2.47 wte. Additional clinical services vacancies were 1.23 wte. A total 8.29 wte. were on maternity leave, 1.92 wte. on career breaks were included within the 'Staff in Post’ wte.

Midwifery turnover rates across the service in the last 12 months to June 2025 were 9.4% staff which equated to 10% wte leavers. Highest staff turnover was maternity staffing at 4.63 wte leavers.

From July 2024 – July 2025 the trust absence target was 4.2%; the overall maternity department absence was 3.4%.

Recruitment:

Recruitment policies and guidance supported staff when new staff were recruited for the service. Trust statistics confirmed all staff had disclosure and barring service checks and held their professional licenses.

The service was currently recruiting new midwives. Interviews were taking place for a clinical educator and recruitment and retention midwife. The service had recruited 2 band 6 midwives who would lead intravenous therapy. An additional bereavement midwife, 4 wte midwives and from September a vulnerabilities midwife would be in post. The vulnerabilities midwife would support inclusion health groups across the region.

Medical Staffing:

The previous CQC report identified medical staffing numbers were not always sufficient, however, mitigating actions were in place. Where medical staff vacancies existed, the trust had mitigated potential risks through use of locum staff until 1.0 wte consultant and a speciality doctor joined the team. The service had 8 whole time equivalent consultant staff who provided services in obstetrics and gynaecology. Of these, one consultant was part-time, and another consultant worked in gynaecology only. Three staffing incidents were documented over 12 months which identified a shortfall in consultant staff presence. Actions were identified for these staffing shortfalls; all 3 incidents remained under review.

Duty rotas identified medical support 24/7 with the inclusion of first and second on-call doctors and a designated consultant. The on-call duty rota was a 1:7.5 with consultant on site presence. One non-resident consultant provided on-call cover from 20.30 – 08.00. Where there were gaps on rotas medical staff filled the gaps.

Staff said medical staffing worked as people were flexible and the second on call system worked well. It was unusual for consultant level staff to step down. Consultant staff supported clinical escalation by covering clinics or wards when times were busy for the consultant of the day.

Mandatory Training:

The previous two CQC assessments identified shortfalls in mandatory training compliance. Staff confirmed the training target as above 90%. We observed comprehensive mandatory and role specific training available for midwifery, medical and additional clinical staff groups. In total 62 training categories were identified for midwives and 35 for medical staff. Role specific training was identified by 37 categories.

At this assessment training statistics confirmed continuing non-compliance as compliance below 90% was identified for 30 categories for midwives and 26 categories for medical staff. All staff groups non-compliance, below 90% ranged from 32% to 88%. We noted 5 training categories’ compliance was from 87% - 89%, the remaining training categories compliance was from 86% to 32%. Practice assessor training at 54% was recently introduced and due to reach target compliance by February 2026.

Discussions with staff said attendance at mandatory training was scheduled however, on rare occasions training could be cancelled at short notice if there was sickness and / or low staff numbers.

Appraisals:

In the two previous CQC reports shortfalls in appraisals were reported. The trust appraisal target was 90%. Appraisal statistics until 29 July 2025 confirmed 91% of staff overall had received an appraisal in 2024/25. Shortfalls in appraisal completion were seen for maternity staff as 87.23% had received an appraisal up to 29 July 2025.

Induction and Clinical Supervision:

Managers provided new staff with appropriate induction. Newly qualified staff completed an 18 month preceptorship package which included rotation across all areas within the service. New band 5 midwives preceptorship packages were tailored to their needs.

Clinical supervision of staff was undertaken by the ward managers; however, we were not informed of the frequency of this supervision over the last 12-months. Managers ensured staff had access to regular team meetings.

The General Medical Council education data tool confirmed medical staff received clinical supervision. Compliance was 97% in 2024 and to-date for 2025 was 93.57%. Clinical supervision out of hours statistics had increased to 94.64 from 92.50 in 2024.

Service Specific Training:

The trust 2022 CQC report identified the service had not achieved its target for life support training attendance. The maternity mandatory, role-specific and role-based training compliance report - by staff group dated 29 July 2025 confirmed the levels of compliance; the training target had increased to 90%. The compliance report confirmed some categories were not achieved against the 90% target; however, we saw some improvements as compliance scores had increased to those previously.

Midwives’ newborn life support training compliance was 92%. The training report did not identify whether medical staff were required to complete newborn life support training. The report confirmed 81% of medical staff and 100% of additional clinical services staff had completed adult basic life support with paediatric modifications training. Adult L3 immediate life support training showed 5 (45%) of 11 midwives had completed this annual training and 82% of midwives had completed the 5-year immediate life support training.

The trust had achieved its target for medical and midwifery staff training in the annual Practical Obstetric Multi-Professional training (PROMPT) training, cardiotocograph (CTG) training and fetal well being competency assessment training. Simulation training had taken place during July 2025. Annual pool hoist training was introduced at the end of 2023; to-date, 95% of midwives and 93% of maternity support workers had completed this training. Midwives at band 6 and above received informal triage training from the fetal well being midwife prior to working in the MAC; followed by 1 week’s observation. Triage training records were not seen.

Staff completed competency-based assessments prior to carrying out specific roles. The ultrasound presentation scanning training package was built into the midwifery preceptorship programme for midwifery staff. Competency completion records for iv drug administration, cannulation, perineal suturing confirmed staff completion of this training to-date. Staff described cannulation training as difficult to access. Training statistics confirmed 21 staff (of 131 staff) had completed cannulation training.

Band 2 staff within the MAC completed the maternity support workers skills and competencies booklet. We observed band 2 staff doing women’s observations and entering them on the electronic system during the assessment. Leaders said assessment of band 2 staff in maternal and neonatal monitoring was planned.

We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

We scored the service as 3. The evidence generally showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The policy on infection prevention and control identified a review date of 1 November 2025. The policy identified levels of accountability and the associated procedures which supported the IPC practices at the hospital. Healthcare associated infection (HCAI) prevention and control was coordinated across the hospital and community services by the Director of Infection Prevention and Control (DIPC) who reported to the trust board. In addition, IPC committees met monthly and / or quarterly.

In the last 12 months, there was one case of HCAI across all maternity locations. Staff said a lot of work had been undertaken to reduce wound infections. Staff attend a session on pressure area care facilitated by Tissue Viability so all midwives would be trained in tissue viability by the end of the year.

Following the assessment the service provided the Legionella testing report and outcome for the birthing pools on the unit, both tests confirmed legionella was not detected. However, the latest Legionella testing report and outcome for the entire maternity unit was not received.

Throughout, the maternity service environment we observed that most areas were visibly clean and well maintained. Staff said IPC learning with the teams was shared through emails, 2-minute messages, the online information Padlet and, review of pressure ulcer incidents.

Staff adhered to infection control principles, including hand washing. Staff were observed to have bare arms below the elbow and used hand gel on entry and exit to clinical areas. Supplies of personal protective equipment, for example, gloves, masks, cleaning wipes were seen throughout the service, however, we did not see aprons in the antenatal clinic. Hand washing facilities were available and hand washing guidance was displayed throughout the service.

Cleaning records were up to date and demonstrated that ward areas were cleaned regularly. Estates staff confirmed their attendance at Infection prevention and control (IPC) meetings, there was good oversight, and joint reviews had taken place with clinical staff.

Staff maintained equipment well and most equipment was clean. We did not see ‘I am clean’ stickers on equipment in the antenatal clinic. Sharps bins were dated with their safety enclosures in place in the antenatal clinic. We observed some dust on fans in the antenatal clinic and early pregnancy assessment unit. Clinical areas had fabric curtains which were not dated to show when they were last cleaned. There was no guidance of how to change the curtains in an emergency, or any records of changes having taken place. We asked the clinical staff about the cleaning process associated with the fabric curtains and staff told us they were not aware of the frequency of cleaning of the fabric curtains and whose responsibility this was to ensure all curtains were cleaned and the frequency of cleaning. We spoke with a manager who confirmed that clinical staff were responsible for ensuring fabric curtains were cleaned regularly and / or when required.

Toys were in the antenatal clinic waiting room; toy checks and cleaning records were recorded.

The IPC audits / outcomes for the last 12 months for all clinical areas within the maternity service identified movement in audit outcomes from 2024 to 2025: Delivery suite outcomes improved to 90.7%, whilst Pannal ward IPC outcomes decreased to 82.1%.

In 2025 hand hygiene compliance improved across maternity services. Delivery suite and Pannal ward / MAC quarterly hand hygiene audits for 2025/26 for quarters 1 and 2 were: Delivery suite– Q2– 100% and Pannal ward / MAC – Q1 – 79.2% and Q2 – 100%. Data for hand hygiene audit outcomes for the maternity community team was not provided.

Monthly cannula audits (2025/26) on Pannal ward confirmed compliance was 100% (April 2025) and 80% (July 2025). The service did not audit the Delivery suite as patients were transferred to Pannal ward so were captured in their audit data. Peripheral cannula audits on Pannal ward from September to March 2025 confirmed compliance from 70% (March 2025) to 100% (September to November 2024).

Following the review of these audits we could not be assured of IPC practices in all areas. We did not receive details of any community IPC audits. The IPC data provided for the maternity unit confirmed some shortfalls in practice.

We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

We scored the service as 3. The evidence showed a good standard; however, we observed some shortfalls in practice and audit processes. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

We spoke to a total of 12 members of staff including ward-based midwifery and maternity staff and the pharmacy team. We visited the early pregnancy assessment unit (EPAU), antenatal department, maternity assessment centre (MAC), Delivery suite (DS) and Pannal ward, and checked areas where medicines were stored in all these areas. We reviewed the records of 4 patients, provider policies and audits.

Medicines were prescribed using an electronic prescribing and medicines administration (ePMA) system. We looked at 4 records and found allergies and weights were always documented to ensure medicines were prescribed safely. All patients had anticoagulant prescribed correctly according to their weight. Prescribers and midwifery staff had access to resources which ensured medicines were prescribed correctly which included a system in-built midwife exemptions formulary and antimicrobial prescribing templates. However, we saw some peoples records with missed doses. When asked to investigate, staff could not find the reason why these medicines were missed as not enough information had been recorded by staff on shift. Currently there are no missed dose audit reports for maternity services.

The trust had up to date policies for antimicrobial prescribing for maternity services including for pregnancy and post-partum. All records seen, patients were prescribed antimicrobial's following trust policy and guidelines and as per the annual report of the ‘Antimicrobial Prescribing 2024-25’, a trust-wide antibiotic audit results showed appropriate prescribing in over 80% of cases.

The trust provided mandatory medicines management training for various staff groups. Following the inspection the trust submitted training figures and the latest compliance data (November 2024) showed 89% for acute hospital staff and 91% for community staff, were compliant against a trust target of 90%.

Medicines were reviewed regularly on ward rounds. There was no dedicated pharmacist for the maternity wards, however staff knew who and how to contact the pharmacy team if they required advice.

Medicines including controlled drugs (medicines requiring additional control due to the potential of misuse) were stored securely and stock was checked daily by 2 members of staff.

Room, fridge and freezer temperatures where medicines were stored were monitored however, we saw inconsistencies on how these were done for example Delivery suite only recorded the fridge current temperature which did not follow trust policy.

When speaking to staff we were not assured they understood when to escalate in case of temperature excursions. For example, in Pannal ward, there were records of ambient temperatures in the clinic room where medicines were stored reaching 30 degrees when they should be below 25. There was no record of any actions taken. Moreover, we found medicines were stored in locked cupboards within the antenatal department and the maternity assessment centre, but ambient temperatures not monitored. This was fed back to the relevant teams for action as we could not be assured this stock was being stored appropriately and safe for use.

There were clear processes to report and investigate incidents when they took place and staff we spoke to understood duty of candour. There were multiple channels for sharing learnings from incidents however, in Pannal ward we found the drug trolley untidy with loose strips and loose anticoagulant pre-filled syringes of different strengths being stored together which is conducive to picking errors. When asked, staff told us that due to a recent incident where the wrong dose of anticoagulant injection was administered to a patient, the new practice was that these pre-filled syringes should always be stored within their packs. This showed that new practices implemented from incidents were not always embedded within staff.

The 2022 CQC assessment identified concerns which related to regular checks on life saving equipment not always being completed. At this assessment we checked the resuscitation trolley on Delivery suite with a midwife present. We found some out of date pieces of equipment and pre-drawn up 10ml saline syringes in the resuscitation trolley. This was escalated to the midwife and senior midwifery team. We rechecked the resuscitation the next day and saw that there was no longer any out-of-date equipment or saline present. In response to these findings the trust has also confirmed a 6-monthly audit process was in place with the specialist resuscitation team, a review of the use of My Kit Check was taking place and the team were undertaking random spot check audits.

Resuscitation trolleys for adults and babies were in place on the ward. We were told the equipment was checked daily and contents were checked after each use or once a month however this was not being done. Records were not being completed appropriately, and we found emergency resuscitation medicines that had expired. The team promptly organised for their replacement.

The pharmacy team completed an annual medicines management audit with the last being completed in January 2025. Some of the issues raised during this inspection had been identified by the pharmacy team.