James Paget Hospital

On this page

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

We rated safe as requires improvement. We assessed 8 quality assessments.

There was a culture of safety and learning. Risks were dealt with willingly as an opportunity to put things right, learn and improve. Staff felt confident to raise concerns. Incidents were investigated and feedback given to staff to change practice if required.

Safety and continuity of care was a priority throughout people’s care journey. There were systems in place to ensure a collaborative, joined-up approach to safety that involved women, along with staff and other care partners. There were effective systems and processes in place, and a strong awareness of the risks to people across their care journeys. However, paper patient care records could not all be used safely without risk of losing information, which put women at risk of staff not knowing their current medical care needs.

People using the service were informed about any risks and how to keep themselves safe. Risks were assessed, and people and staff understood them. Risk assessments about care were person-centred, proportionate, and regularly reviewed.

People were cared for in safe environments that were designed to meet their needs. Maternity triage did not provide a clear view of women waiting to be seen. However, the service had plans to move the maternity triage to a purpose-built area, more suited to women’s needs. Wards and units were secured through the use of a buzzer entry system, although staff were not close enough to entry doors to prevent unauthorised visitors. Ward areas were visibly clean during our visit and cleanliness audits showed a high level of compliance.

Recruitment practices were safe. However, compliance with training did not always meet the trust target. Staffing levels met planned levels. Regular staffing reviews and the use of the Birth-rate Plus Acuity Tool ensured staffing concerns were escalated and mitigations put in place to reduce potential risk. Staff received training that was relevant to their roles and responsibilities, along with the necessary support to ensure the delivery of safe care.

The approach to medicines generally reflected current and relevant best practice and professional guidance. However, not all staff had completed the required training. Most medicines were appropriately prescribed, supplied, and administered in line with relevant legislation and current national guidance. The service monitored records for incidents and errors, found trends and themes and developed actions to reduce the number of these occurring.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The service had a proactive and positive culture of safety and lessons were learnt to continually identify and embed good practice.

Staff we spoke with knew what incidents to report, how to report them, through a variety of avenues, including the trust’s freedom to speak up guardian (FTSUG), and felt encouraged doing so. Senior midwives told us managers debriefed and supported staff after any serious incident as part of the after actions review (AAR).

A process and policy was in place for staff to raise concerns, which ensured members of staff were aware of their duty of candour, openness, and transparency, and to put in place a mechanism for them to raise concerns at work. Lessons were learned from safety incidents and complaints, resulting in changes that improved care for others. Staff told us they received feedback from incidents they had reported, which was provided by email to individual staff and shared with the wider team in team meetings, handovers and safety huddles. We observed learning from incidents being discussed at handovers and huddles.

The trust also reported working in collaboration with other trusts within the Local Maternity and Neonatal System (LMNS) to share learning regarding swab safety. The LMNS is a partnership between the service and relevant stakeholders within Norfolk and Waveney. The system worked to develop and transform maternity services in response to local needs and national recommendations.

Compliance audits to monitor the effectiveness of the service were completed by managers and leaders. For example, time taken to triage dependent on the identified red, amber, green RAG rating and audits of modified early obstetric warning score (MEOWS).

A duty of candour policy was in place to provide staff clarity on their obligation with regards to being open and the duty of candour.

The service worked to establish and maintain safe systems of care, although inpatient records were not secure and important information was not always stored securely. However, they made sure care was provided in line with national guidance, such as the National Institute for Clinical Excellence and the Royal College of Obstetrics and Gynaecology.

At our last inspection we found concerns around the auditing of documentation audits. During this assessment we found completed audits of documentation and leaders had a good understanding of further work they needed to complete.

Women's inpatient notes were not always secure. Inpatient records were recorded in paper notes. These notes were often loose, not in chronological order and did not provide a reliable or safe method for sharing information with staff. We found loose documents in 2 of 11 patient records that either lacked patient details or contained important safeguarding information on the reverse of a patient sticker for monitoring testing. Incidents recorded by staff in 2024 and 2025 showed 15 entries where different patient records or staff notes were found in patients records. This meant patient records were not always safely stored and put women and babies at risk of not receiving required care and treatment.

Staff used an electronic patient record (EPR) system for antenatal and postnatal community held records, which all relevant staff had access to. This meant there were no delays in staff accessing women’s records when they transferred to a new team or area. However, not all of the staff working in the hospital environment knew where to access some of the important safeguarding information on this system. This meant information recorded by community midwives may not be easily accessed by hospital midwives and increased the risk of inappropriate action by staff. Service leaders told us they were aware of the issues regarding paper records and planned on rolling out the EPR system for inpatient records in 2026.

Staff used a nationally recognised early warning tool to identify women, birthing people and babies at risk of deterioration. We reviewed care records for 11 women and babies. Risk was assessed at every point of contact throughout their care journey, with clear documentation and appropriate action taken.

Staff completed audits to monitor the use of nationally recognised tools for identifying deterioration, including the maternity early warning system (MEWS) and newborn early warning track and trigger (NEWTT). Audits reviewed from June to September 2025, showed consistently high compliance, averaging over 95% for both tools. High scoring entries were either repeated or escalated as appropriate. We found to be reflected in the records we reviewed during our visit.

Situation, background, assessment, recommendation (SBAR), (an acronym for framing clinical communication) audits had been completed each month. Information for the 12 months before this assessment showed the SBAR tool was used appropriately in 96% of records examined. However, staff members completing the tool needed to be more accountable with recording their names and roles.

The service had adopted the use of the Birmingham symptom specific obstetric triage system (BSOTS) which is an evidence based risk prioritisation tool used in maternity services. This is a system used to assess how quickly women presenting with pregnancy related concerns should be seen, based on their clinical need. Prioritisation was undertaken using a red, amber, yellow, green (RAG) rating system and then recorded in the patient records. According to the tool and local policy women should be seen by a midwife within 15 minutes of arrival and prioritised as either red, orange, yellow or green. Each colour identified how soon women should be reviewed by a doctor or midwife as required. A red rating required immediate transfer to labour ward, orange required a review within 15 minutes, yellow required a review within 1 hour and green required a review within 4 hours.

During our visit we observed that all but one woman was seen by a midwife within 15 minutes of arrival. Triage audit data for the 12 months prior to our assessment demonstrated an average compliance of 88% with the 15 minute initial midwife review. All women rated red were seen immediately, and 91% of those rated amber were reviewed by a doctor within 15 minutes.

The service operated a 24 hours a day, 7 days a week, telephone triage service to provide advice and guidance for women contacting the service, that dedicated telephone triage midwives were responsible for providing. Midwives used the service’s telephone triage proforma and kept the paper records safely until they were added to the patient notes. The proforma was in place to ensure all midwives asked women the appropriate questions during the telephone assessments, to determine whether women needed to attend the unit. However, we found there was no dedicated telephone triage midwife and triage midwives were taking calls during our visit. This meant during busy periods answering the triage telephone may not take priority and puts women needing advice at risk of not getting this quickly enough.

Staff followed the service’s baby abduction policy and explained to us how this worked. Ward areas were secure and a baby tagging system was in operation. Staff had rehearsed the procedure for responding to a baby abduction within the 12 months prior to our assessment.

Operating theatres staff achieved 99% overall compliance with the World Health Organisation (WHO) surgical checklist audit for the 12 months preceding this assessment.

The service also operated a separate maternity assessment unit and birthing centre, with their own staff and admission criteria, ensuring women were seen in the most appropriate setting.

Most staff had training on how to recognise and report abuse, and they knew how to apply it. The service worked well with other agencies to do so. However, staff guidance was not specific to the service and staff could not find where safeguarding information was stored on electronic records.

There was no safeguarding policy specifically for the maternity service, so staff relied on the trust’s adults and children’s safeguarding policies, which were not always applicable. The existing policy was in date and version controlled. Information provided following this assessment told us additional guidelines were available for maternity specific guidance, such as for women from overseas. Staff were also able to obtain support and guidance from the Eden team, who provided oversight of families who needed additional support. However, this meant maternity staff did not have specific guidance about the additional questions asked by maternity staff or actions to take in specific situations.

Staff asked women safeguarding questions throughout their maternity journey to ensure they were protected. However, some staff working in inpatient areas were not aware of where domestic abuse information was recorded in the electronic records used by community antenatal teams.

Midwifery staff had received training specific for their role on how to recognise and report abuse. The service provided nursing and midwifery staff with level 3 safeguarding training for children and adults. At the time of our assessment, the compliance rate for midwifery staff was 94% overall, which exceeded the trust’s target of 90%. The service provided medical staff with level 3 safeguarding training for children and adults. At the time of our assessment, the compliance rate for medical staff was 84% overall, which did not meet the trust target of 90%.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. Staff were able to describe ways to safeguard women from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff also knew how to identify adults and children at risk of, or suffering, significant harm and knew where to document and access this information. Staff told us the safeguarding team was very visible, and staff were able to clearly identify the named safeguarding midwife.

The maternity ward had security measures in place to prevent baby abduction. Staff were familiar with the baby abduction policy, which was in date, and they participated in baby abduction drills. The trust reported that the most recent baby abduction drill had taken place within the 12 months before our visit. Information provided following our assessment confirmed that the exercise had been successful and staff had followed the policy as expected.

Staff provided care to meet people’s needs. However, staff did not always complete fetal monitoring risk assessments in line with national guidance.

Staff completed fetal monitoring risk assessments in line with national guidance. During labour, they attached high-risk women to a cardiotocograph (CTG), which was used to monitor fetal heart rate and uterine contractions. According to the national institute for health and care excellence (NICE) guidelines NG229, staff must carry out an hourly fresh eyes review of the CTG trace for any woman attached to a CTG during labour. Two clinicians must carry out an hourly fresh eyes review during the intrapartum period, assess the CTG trace together, and document their findings to ensure it is safe for the baby to continue with labour. Audit data showed that from March to September 2025, staff met the trust target of 90% compliance for completing hourly fresh eyes reviews. However, compliance was lower for recording key details, including staff details, time of the check and whether the second clinician agreed or disagreed with the with the decision made.

Staff assessed whether each woman was high or low risk at booking and reviewed this at each antenatal appointment. Staff did this to ensure women received the appropriate care.

Staff used a nationally recognised tool to identify women at risk of deterioration. The service used the maternity early warning score (MEWS) chart to document women’s observations. The MEWS charts we reviewed were completed, scored and escalated appropriately when required. Audit data provided by the trust showed over 90% compliance in the use of MEWS charts and related actions between June and August 2025.

Staff completed newborn risk assessments at birth using recognised tools and reviewed these regularly. Staff assessed each newborn to determine whether the baby required regular observations. When needed, staff used the neonatal early warning trigger and track (NEWTT) chart to document neonatal observations. The NEWTT charts we reviewed were completed, scored and escalated appropriately when required. Audit data from the service showed more than 95% compliance in the use of NEWTT charts and appropriate escalation.

Staff also completed venous thromboembolism (VTE) scoring in the notes of women we reviewed onsite.

The service provided transitional care for babies who required additional care, this was managed by a midwife with support from a neonatal nurse.

Staff completed the World Health Organisation (WHO) 5 steps to safer surgery checklist prior to starting surgical procedures. The checklist provides essential safety checks to protect women before, during and after surgery. The WHO checklists we reviewed were completed appropriately. Audit data provided by the trust showed 99% compliance in the use of the WHO checklist between November 2024 and September 2025.

We observed good multidisciplinary working across the unit. Handovers and safety huddles involved all relevant members of the multidisciplinary team, followed a structured format, and took place in an area with minimal disruptions. Shift changes and handovers consistently included key information to keep women and babies safe.

The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use them. Staff managed clinical waste well.

The design of the environment did not always follow national guidance. The unit was open 24-hours a day, 7 days a week. Inpatient maternity services at the hospital consisted of a maternity assessment unit (MAU), triage unit, birth centre, labour ward and maternity ward.

Space in the maternity triage was limited and did not provide a clear view of women waiting to be seen. Staff confirmed a new triage unit was planned and would provide a more appropriate area for women.

Each ward or unit was fully secure with a buzzer entry and exit system monitored by ward clerks and maternity staff. During our assessment, we observed that entry to all areas within the service was operated appropriately by staff. Ward clerks confirmed visitors’ identity before granting access.

Birthing partners were supported to attend and provide support to women in all areas within the service. The service also provided bereavement facilities for families experiencing fetal loss. The bereavement room had adequate facilities to meet the needs of families, however it was located within the labour ward. Although this was not in line with the national bereavement pathway recommendations, the bereavement suite had an additional entry away from birthing women.

The service had enough equipment to help them to safely care for women and babies. This included but was not limited to CTG monitors, sonic aids and observation machines.

Staff had access to emergency and safety equipment and mostly carried out daily checks on them. Emergency equipment included but was not limited to neonatal resuscitaires, adult resuscitation trolleys, post-partum haemorrhage (PPH) trolleys, eclampsia trolleys and glucometers. We observed minimal gaps in emergency and specialist equipment whilst onsite. Audit data supplied by the service showed overall compliance for completion of these checks to be above 90% in all areas. Most areas completed checks at a rate above 95%.

Women could reach call bells, and we observed staff responding quickly when called on the maternity wards. Staff disposed of clinical waste safely, we observed sharps bins being filled within a safe limit and clinical and domestic waste was segregated and labelled correctly.

The service made sure there were enough qualified and experienced staff, although not all medical staff completed the trust mandatory training. Staff worked together well to provide safe care that met people’s individual needs.

At our last inspection we told the service there were insufficient numbers of qualified, skilled, competent and experienced staff. During this assessment we found the service had enough midwifery and medical staff to keep women and babies safe. During this assessment the numbers of midwives, maternity support workers and medical staff mostly matched the planned numbers in all areas. However, at the beginning of our onsite visit when there was only one midwife in triage, who also had responsibility for a woman in another area close to delivery suite. Additional staff were scheduled to work in triage within half an hour of our visit, although only having one staff member for different areas potentially put women at risk of not being assessed quickly enough.

The service had a good skill mix of medical staff on each shift and reviewed this regularly. The number of consultants had increased since our last inspection, which meant there was adequate cover each week for out of hours and emergency work. Consultant sickness rates had also improved since our last inspection, from 5 out of 11 staff on sick leave to an average of 1.6% (approximately 7 days) sick leave each month since January 2025. The service reported that they always had an obstetric and anaesthetic consultant on call during evenings and weekends, with additional staff on call during twilight hours. Although consultants continued to cover both obstetrics and gynaecology, they told us they were better able to escalate to colleagues when support was required. Staff recorded the only 3 incidents in 2024 and 2025, regarding unavailable consultants and other medical staff, in April and May 2025. Staff records showed there was higher than usual sick leave in August 2025. In 2 incidents, this affected the speed that women in triage were reviewed by medical staff. Medical staff told us they had good staffing levels.

The service had a matron and a labour ward coordinator on every day shift. These staff were supernumerary and had oversight of the staffing, acuity, and capacity within the unit. They adjusted staffing levels and skill mix daily according to the needs of women. There were 23 red flags in the 6 months before this assessment, raised when the labour ward coordinator could not remain supernumerary and was required to support other staff. During this period, there were no reports of the coordinator being required to provide one to one care.

The service used the birth rate plus acuity tool to determine the number of midwives required on the maternity unit. Midwives in charge completed these calculations several times a day. According to the service’s safe staffing report for the local maternity and neonatal system (LMNS), the Birthrate Plus recommended ratio of 1 midwife to 22 women, while the service’s actual ratio achieved an actual ratio of 1 midwife to just over 19 women.

The service had a safety huddle twice a day, which covered staffing, acuity levels, safeguarding, concerns in each area, discharges and learning from previous incidents or complaints. We observed evidence of good multidisciplinary working.

The service monitored maternity ‘red flag’ staffing incidents in line with NICE guideline: Safe midwifery staffing for maternity settings. A midwifery ‘red flag’ event is a warning sign that something may be wrong with midwifery staffing. The service recorded 45 red flag events in the 6 months before our visit. Most of these were related to the labour ward coordinator not being supernumerary and delays in induction of labour. One to one care in labour was mostly maintained, with one red flag indicating this had not been possible. The service undertook an audit of this data to identify the causes of red flag events and was actively working to reduce delays.

The service’s staffing, vacancy and turnover rates were assessed as part of work with the LMNS and integrated care board (ICB). This was completed in March 2025, with information from January 2025. The overall vacancy rate for maternity staff was 2.5% for midwives, although the rate was higher for maternity care assistants (MCA) at 6.94%. There was a 28% vacancy rate for maternity administration staff. The overall voluntary turnover rate for midwives and MCA staff was 4.17%. However, the sickness rate for maternity staff was 2.49%, against a trust target of 2.25%, although long term sickness rates were reducing. Medical staff sickness rates were in line with the trust target.

The service used regular bank midwives who were familiar with the service. Managers ensured all bank and locum staff had received a full induction to orientate them with the service’s systems and processes. Information received from the service told us no short-term medical agency/locum staff were used and no long-term medical agency/locum staff had been used since May 2025.

The service completed a review of midwifery staffing in May 2025 and found that leaders and senior managers could not properly assess staffing in their areas as financial budgets were not aligned with clinical areas. It also identified the need to include training hours in uplifted hours.

At our last inspection we had concerns about the safety of women who needed enhanced care and whether staff received adequate training to properly carry out care of these women. Staff told us enhanced care training had been developed by the practice development team and was being embedded with a focus on delivery to those staff with primary responsibility for caring for women who needed additional support.

The trust provided maternity specific and statutory mandatory training that was comprehensive and met the needs of women and staff. Midwifery staff were compliant with their training requirements. The training included but was not limited to infection control, equality and diversity, adult basic life support, newborn life support, maternal medicine and practical obstetric multi-professional training (PROMPT). Overall compliance for maternity specific and statutory mandatory training was 93%, which exceeded the trust target of 90%.

Medical staff also received their maternity specific and statutory mandatory training. Overall, 90% of medical staff had completed maternity specific training, although there were areas where completion fell below 90%. Compliance with the trust’s mandatory training, however, was 78%.

The practice development team monitored midwifery and medical mandatory training. Staff we spoke with reported they were automatically booked on to training when this was due.

Managers supported staff to develop through annual, constructive appraisals of their work. Data from the service showed 91% compliance with appraisals for midwifery staff, compliance rates for medical staff was 96%.

The service controlled infection risk well. Staff used equipment and control measures to protect women, themselves, and others from infection. They kept equipment and the premises visibly clean.

Maternity service areas were visibly clean and had suitable furnishings which were clean and well-maintained. Wards had recently been refurbished to the latest national standards. Cleaning records were up-to-date and demonstrated that all areas were cleaned regularly. The service performed well for cleanliness.

Staff followed infection control principles including the use of personal protective equipment (PPE). We observed all staff were bare below the elbows while working. Service leaders completed regular infection prevention and control and hand hygiene audits. Data showed both infection prevention and control, and hand hygiene audits were completed in all maternity areas. From July to September 2025, overall compliance was consistently above 95%, with a drop in one area on one occasion. Records show action was taken immediately to address any shortfalls.

Staff cleaned equipment after contact with women and birthing people. Staff cleaned couches between use in the antenatal clinic and it was clear equipment was clean and ready for use.

Not all staff had completed mandatory medicines training. The service used systems and processes to safely prescribe, administer, record and store medicines.

The service provided staff with mandatory medicines training. Although some staff groups and areas were 100% compliant with this training, others’ compliance was 80 and 86%. Overall, 84% of maternity staff had completed the training, compared with a trust target of 90%.

The service monitored records for medicines incidents to determine any trends and themes. Although all incidents scored similarly in numbers, drug administration errors and prescription or medicine chart issues were the highest. Actions were identified, together with prompts and teaching aids for staff, and consideration for alternative medicines if appropriate.

Staff followed systems and processes to prescribe and administer medicines safely. Women and birthing people had paper prescription charts for medicines that needed to be administered during their stay.

We reviewed prescription charts and found staff had completed them accurately and kept them up to date. Midwives could access the full list of midwife exemption medicines, so they were clear about administering within their remit.

Staff stored and managed all medicines and prescribing documents safely. The clinical room where the medicines were stored was locked and could only be accessed by authorised staff. Medicines were in date and stored at the correct temperature. Staff monitored and recorded fridge temperatures and knew to act if there was variation. Staff checked controlled drug stocks.

Staff followed national practice to check women and birthing people had the correct medicines when they were admitted, or they moved between services.