Musgrove Park 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 inadequate. At this assessment the rating has improved to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment, environment, medicines management and safeguarding.

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.

We scored the service as 2. The evidence showed some shortfalls. The service did not always have a proactive and positive culture of safety. Not all incidents were reported and therefore opportunities were lost to investigate safety events.

Staff knew what incidents to report and how to report them, however some staff told us they did not have time to report incidents. Some staff told us they were not always reporting issues such as long waits in triage, women or pregnant people self-discharging or staff receiving verbal abuse from patients or their relatives consistently. However, the service highlighted themes from incidents reported in February 2026 as delays in obstetric review on maternity triage also resulting in self-discharges, delays in transfer to Labour ward for induction of labour continued care, theatre capacity issues, delays in elective caesarean pathways and reduced staffing. Whilst the themes were known by leaders, and some actions had been taken to address these; there was a risk the extent to which the issues were occurring were unknown.

Between 1 October 2025 and 9 March 2026, 318 maternity-related incidents were reported using the Patient Safety Events (LFPSE). Examples included post-partum haemorrhage, safeguarding concerns and medication errors. At this inspection improvements were seen because leaders were now looking at outcomes related to ethnicity. However, leaders had commissioned a system to support with aligning their performance monitoring with the NHSE making data count programme because they felt further improvement was required. Until this system was active, staff told us they manually assessed and logged from existing forms these characteristics for their learning. The service had plans to develop their own informatics with a dedicated digital information team within the maternity service.

The national perinatal mortality review (PMRT) standardised process was followed in the event of baby deaths. The trust criteria had recently changed to ensure the most serious patient safety incident investigations (PSII) were escalated to senior executive level for further scrutiny. We saw evidence from governance meeting minutes that less serious concerns and incidents were reviewed, and this was overseen at a senior level. However, it was unclear how patient safety incident management or investigations, which were conducted within the same service group, were independently reviewed.

We were sent copies of perinatal mortality review meeting minutes following our site visit. We saw details of action logs and some of these included sharing the findings with other stakeholders.

The service also reported incidents to the Strategic Executive Information System (StEIS). There were 11 incidents reported between March 2025 and March 2026. There was 1 death, 3 injuries causing serious harm and 7 injuries requiring treatment to prevent death or serious harm. Whilst the incidents should be recorded immediately, 8 out the 11 had taken over 90 days. The service had not been reporting to StEIS if, for example, a report had already been made to the Maternity and Newborn Safety Investigations team.

Maternity units report to Maternity and Newborn Safety Investigations (MNSI) for specific and severe maternity incidents to promote learning and prevent future harm. The service told us they had retrospectively uploaded incidents to StEIS. It was unclear whether changes had been made to the policy to reflect this.

These incidents included a number of babies requiring therapeutic cooling. (This is a treatment where a newborn baby’s body temperature is lowered to reduce brain injury after a traumatic event such as oxygen deprivation). Although incidents were discussed and managed through daily safety meetings, delays in formal StEIS reporting created a risk that organisational oversight, external visibility, and assurance regarding investigation progress could be delayed. The immediate management of incidents mitigated some patient safety risks. However, delayed reporting weakened the governance framework intended to support timely escalation, scrutiny and learning.

Staff understood the duty of candour and gave patients and families a full explanation if and when things went wrong, which was an improvement from our last inspection.

The service had introduced weekly patient safety learning forums to discuss patient safety incidents and events which had been selected based on their potential for learning opportunities. These followed the trust patient safety incident response framework policy. We saw reviews completed 3 days after an incident had happened. Themes had been identified, immediate learning actions noted and were reported to the maternity and newborn safety investigation (MNSI) team where necessary. There had been 4 referrals to the MNSI team and 1 report received between October 2025 and February 2026.

The service was worse than the national average for 3rd or 4th degree perineal tears (this is an injury sustained during instrumental birth, particularly when using forceps). As a result, there was a quality improvement (QI) project to review the care bundle at instrumental delivery. Training was delivered through practical obstetric multi-professional training (PROMPT). There were two other QI projects, including triage and an escalation charter.

Information for women about how to make a complaint or provide feedback was available. Staff told us they knew the procedure to follow if a woman or their family/partner wanted to raise concerns.

Patient safety events were reviewed and improvement actions identified. For example, in November 2025 there had been a neonatal life support incident. The SWARM huddle (a SWARM huddle is a rapid, no-blame debriefing tool used in healthcare to analyse patient safety incidents immediately after they occur) identified the need for additional simulation training. Updated guidelines were incorporated into the PROMPT training.

There had been 5 ‘red flag’ events between January and February 2026. A midwifery red flag event is a warning sign that something may be wrong with midwifery processes and staffing. The ‘red flag’ events included 2 delayed or cancelled time critical activity, 1 missed or delayed episode of care, 1 delay in providing pain relief and 1 delay between admission for induction and the beginning of the process. The monitoring of red flags included 1 to 1 care in labour. The service investigated red flags and took action to mitigate risks.

We scored the service as 2. 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 used the Birmingham symptom specific obstetric triage system (BSOTS) which is an evidence-based risk prioritisation tool used in maternity services. This was an improvement. The triage tool was used to assess how quickly women should be seen based on their clinical needs and attributed a colour coded rating system to prioritise care. The service provided audit data for this system. Between October 2025 and December 2025, a transfer of 1 red rated patient from triage to labour ward had taken 30 minutes, this was longer than expected for an urgent case and below the target of immediate transfer. Between April 2025 and September 2025, all red rated patients were transferred directly to labour ward.

We saw women identified as non-urgent had waits of up to 10 hours for a medical review. As a result, some women had self-discharged from triage without a plan of care as it was policy only medical staff could provide this. Staff recorded this information by hand in a notebook but did not consistently incident report this. We reviewed the self-discharge notebook and there had been 7 instances between 19 and 25 February 2026; 4 of these had arrived at triage after 5pm and the other 2 had arrived in the afternoon. These remained on the electronic waiting list so the doctors could follow up the next morning. We were told by staff that approximately half of women could wait for more than 4 hours in triage for a doctor review. We were told if a delay of 2 hours or more happened during the day it would be escalated, however at night escalation was for emergencies. We raised this with the service at the time of our inspection, and the weekday (Monday to Friday) doctor shift in triage was extended from 5pm to 8pm finish. An additional doctor shift in triage was introduced at the weekend between 1pm and 8pm.

The BSOTS process states women should be seen by a midwife within 15 minutes of arrival. The data for the 15-minute standard between October 2025 and December 2025 demonstrated 75% compliance. We requested the data for February 2026 which showed improvement to 84%, this was just below the trust target of 86%. During February 2026, the service had targeted training for the triage team. A core team of midwives had been established for triage and there was access ‘to take out’ (TTO) medications. Ongoing midwifery care (orange and yellow) performance had improved in February 2026, increasing to 75-81% compared with previous performance of 66-72%, indicating more timely commencement of care across urgency categories. We were told this was hoped to improve further whilst the training embedded.

A dedicated daytime telephone triage service operated separately, at Yeovil maternity unit. During the evening calls were diverted to Musgrove maternity unit. During an evening observation at Musgrove, a midwife completed a triage assessment and based on the woman’s history, advised her to attend triage. Staff reported they monitored attendance when women were asked to come in. If multiple calls were received simultaneously, urgent callers were redirected to the labour ward number. The service monitored call abandonment rates, which were reported to be low as the phone line was continuously staffed. A standardised template was used for staff self-audits to support learning and review.

The service had a dedicated lead midwife for triage, alongside a new consultant obstetrician lead to chair and drive a multidisciplinary triage working group.

There was a team and theatre available to manage maternity emergencies. This had improved since our last inspection. An elective list was available Monday to Friday mornings and Wednesday afternoons. The procedure room was still used for performing caesarean sections, it was not a theatre despite some improvements to the environment since our last inspection. The trust was part of the new hospital programme but this had been delayed by the national team. (The new hospital programme is a government infrastructure initiative to deliver 41 hospital projects in phases).

We reviewed the most recent audit for category 1 caesarean sections, which must be carried out within 30 minutes of the clinical decision as it is immediately life threatening. The service had improved compliance from 73% in 2024 to 86% in 2025. However, this was below the target of 100%. We reviewed the audit for category 2 caesarean sections, which was 78% compliant and category 3, which was 100% compliant. Category 2 is not immediately life threatening but there is maternal or fetal compromise and category 3 is no maternal or fetal compromise but early delivery is required. This audit was in draft and was with the lead clinician for discussion at the cross-county meeting where the action plan would be agreed. There had been 6 incidents where delays had occurred because either a second theatre team were not available, or a procedure room was not available between December 2025 and February 2026. The planned reopening of Yeovil maternity unit in 2026 was expected to reduce service pressures and support improvement.

The service did not have a day case assessment unit (day case assessment units offer urgent but not emergency assessment and monitoring to prevent overnight admissions). There was a scheduled care area which sat next to the antenatal clinic with dedicated midwifery staffing. (Scheduled care provided planned check-ups where the health of the baby and pregnant person was monitored). Scheduled care at Musgrove dealt with planned appointments which included repeat blood tests, iron infusions and other checks. This was a midwife led service and plans of care were followed. However, there was no doctor cover, and any reviews or escalation had to go through triage. This meant there was a risk of delays to women requiring doctor input. Leaders of the service had raised this with senior executives.

The triage area had moved to a larger footprint with clinical oversight of women by suitably qualified staff. This was an improvement since our last inspection.

There was a flow midwife identified for every shift. They managed staffing levels, flow and any acuity concerns across all trust maternity services. This was in addition to the labour ward coordinator. Staff said they would refer any concerns to them.

There had been 3 women transferred from Musgrove to another hospital for ongoing induction of labour (IOL) due to workload between August 2025 and February 2026. Prioritisation of induction of labour was managed through senior clinical oversight and discussed on ward rounds and at the daily multidisciplinary safety huddle. This provided review of acuity and emerging risks and clinically‑led prioritisation under the leadership of the on-call consultant. It was recognised this process could be challenged during periods of operational pressure. If the on‑call consultant was unavailable to attend the safety huddle, the flow midwife was responsible for agreeing the priorities. A decision to delay was based on clinical priority, a clinical review took place and if the delay was prolonged, capacity at neighbouring units would be explored. These decisions were delayed in the absence of a consultant. Delays were reported to the region daily via the newly launched maternity sitrep. A new induction of labour policy was in the process of being ratified during our inspection. A business case was due to start for the induction of labour pathway to be improved.

Handovers and safety huddles across the unit involved relevant members of the multidisciplinary team and included necessary key information to keep women and babies safe. Ward rounds occurred twice a day.

We scored the service as 1. The service did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not share concerns quickly and appropriately.

Safeguarding had historically been the responsibility of the women requiring extra nurturing (WREN) team. Service leaders had been concerned risk factors were not identified early enough and safeguarding was not responded to in a timely way. As a result, safeguarding was brought back into the duty team responsibility at the end of 2025. Safeguarding support was available for staff through the trust safeguarding advisory service. Some staff were not sure or confident what the process was for reporting safeguarding concerns.

Midwives were not consistently supported by regular, effective, reflective safeguarding supervision, despite there being a supervision policy. Midwives told us they did not have capacity to attend, and protected time was not given to this supervision. This meant there was a lack of professional curiosity which prevented initial exploration of potential risks from domestic violence and a culture of ‘not my responsibility’. We reviewed 13 patient records for safeguarding. Almost half of the records did not demonstrate curiosity in facilitating disclosure of domestic violence through the use of routine enquiry. Most of the records stated ‘unable to ask’ due to others being present. Furthermore, a non-English speaking woman had not been asked at all during her pregnancy, the records stated she declined an interpreter and preferred her husband to translate. When safeguarding advice was sought however, it was documented that an interpreter should be used at future contacts. This meant there was a risk women were not given the opportunity to disclose domestic violence, despite the evidence that domestic violence often begins or increases during pregnancy and people are more likely to disclose when asked directly. We reviewed patient safeguarding records and found evidence of domestic violence but no referral to the domestic abuse service. We observed a midwife had to organise a discharge planning meeting as advice from the safeguarding team had not been followed previously. Where safeguarding supervision was accessed, it was valued by midwives. Supervision sessions and documentation followed the signs of safety model. Women that received care from specialist complex care teams benefited from tenacious and creative working to identify and support those at risk.

Unborn and newborn babies did not consistently have their holistic needs considered and documented. The assessment of the impact of parental behaviours and circumstances on babies did not demonstrate sufficient understanding of how to capture the voice of the child. However, the impact on unborn and newborn babies’ health, development and well-being was evident in the records we reviewed by specialist midwives. This highlighted variability in practice across the service.

We raised concerns around safeguarding during our inspection, and the trust was aware of the risks. A recent rise in incidents linked to missed safeguarding referrals and delayed escalation had prompted a joint review by the Director of Midwifery and Director of Safeguarding. The review identified gaps in early identification and support to staff. An improvement programme had been implemented, with strengthened governance, supervision, clearer referral pathways, enhanced staff support and improved multi‑agency collaboration. We were told a daily phone call between the safeguarding advisory service duty team and postnatal and neonatal areas would take place for real time advice. We were also told the safeguarding advisory service duty team would attend daily safety huddles across both sites from April 2026. Since our inspection, we were told midwives on the inpatient rota were rostered safeguarding supervision and by the end of June 2026, 50% of inpatient midwives had attended a session.

There had been an improvement in compliance for safeguarding adults and children training at designated levels since our last inspection. Overall, the service was 91% compliant for adults and 86% compliant for children level 3 training. This was further broken down to staff group which showed, 91% of midwives and 86% of medical staff were in date for safeguarding adults. Data for safeguarding children showed 88% midwives and 48% medical staff were in date. This did not meet the trust target of 90%.

Simulation exercises for baby abduction scenarios were scheduled quarterly. Feedback from previous training was initial lockdown was sometimes slow. Therefore, the service had developed a lockdown standard operating procedure. Administrative staff also received this training. Security had improved with swipe access and the security team were made aware of risks from the local authority if a named person should enter the building and they were also included in baby abduction training scenarios.

There was a process to send 2 midwives to home visits where there were safeguarding or domestic violence concerns. They had trialled the use of personal alarms, but they were not used at the time of our inspection.

We scored the service as 1. The service did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff communicated with women to ensure they understood their care and treatment. However, the temporary closure of the special care baby unit (SCBU) at Yeovil Hospital, resulted the suspension of maternity services at Yeovil Hospital. Care transferred to maternity services at Musgrove Park Hospital which resulted in delays throughout the delivery pregnancy pathway. The operational pressures escalation levels (OPEL) framework was used to monitor and respond to surges in demand. The unit closed to admissions on 1 occasion in December 2025 as they were unable to meet demand. This was escalated and formally reviewed at the weekly governance meeting. During our inspection we observed delays in triage. When a doctor was not available, some women did not have a timely updated care plan as the policy did not allow midwives to do this. This meant some women self-discharged from triage before doctor review.

The service used the Maternity Early Warning Score (MEWS) tool to monitor women for clinical deterioration, and all patient records we reviewed showed it was completed correctly. However, overall compliance between July and September 2025 was 69%, this was below the 90% target. There was an action plan to improve this. We asked for and did not receive MEWS audit data from September 2025 to the date of our inspection. Therefore, there was no evidence to demonstrate the service was assured that the deterioration of women was being effectively identified and escalated.

Handovers were conducted once every 12 hours. The service audited the use of situation, background, assessment and recommendation (SBAR) in the handover of care. A weekly handover audit was conducted of 5 women on the labour ward at each hospital site, representing approximately 10% of patients between April 2024 and March 2025. Results showed low compliance of 48% SBAR completed before handover and 53% SBAR completed during transfers. The recommendation section was most often incomplete or lacking detail. There was an associated action plan dated 15 October 2025. A re-audit was scheduled for 2026-2027 to allow sufficient time for changes to become embedded. Reporting was on a quarterly basis and the first report due at the end of July 2026.

Fetal monitoring during labour (cardiotocography CTG) audits were reviewed quarterly. This was an improvement. We received data between October and December 2025. The service was 79% compliant for hourly peer review CTG monitoring, alternatively known as ‘fresh eyes’ and 86% compliant for 4 hourly peer review intermittent auscultation (using a handheld doppler) monitoring. This was below the trust target and there was an action plan to improve the position. However, they were compliant for risk assessments at the onset of labour and method of ongoing risk assessment. They were compliant in identifying and escalating concerns. We reviewed 7 patient records and found there was evidence of ‘fresh eyes’, and appropriate escalation.

There was a lack of trust assurance that staff were adhering to sepsis protocols. The most recent audit of the management of sepsis was between April and June 2024. A reaudit was scheduled for 2026. Previously, sepsis was addressed as part of the trust-wide sepsis policy review, with no maternity-specific guideline. However, the sepsis screening tool was integrated within the enhanced maternal care guideline, and teaching on its use was within the 2025 and 2026 PROMPT programme. The service told us they monitored sepsis through spot checks, forum discussion and governance reporting.

The service mostly completed assessments for women’s risk of venous thromboembolism (VTE). A common form of VTE is deep vein thrombosis, when a blood clot forms in the deep veins. If a clot breaks off and flows to the lungs to lodge there, it becomes a pulmonary embolism (a blood clot in the lungs). VTE risk assessment audit data was measured by ward teams. The data results for completed VTE risk assessments for August 2025 to January 2026 showed overall (all wards including antenatal triage, labour ward and post natal ward) compliance was 80%.

The Bracken Birth Centre was accepting postnatal women who were not high risk to help meet the demand. The Bracken Birth Centre was a midwifery led birthing centre based at the hospital. An increase in homebirths had resulted in a lower number of births at the Bracken Birth Centre, therefore there was capacity to accommodate post natal women and offer infant feeding support.

The service was 97% or above compliant with all aspects of the newborn early warning score between October and December 2025. This was an improvement.

There was a process to support women who chose to give birth outside of national guidance. There was consultant oversight and a mutually agreed plan of care was developed.

There was a plan to implement a multi-disciplinary handover room with screens (for antenatal inpatients, post-natal inpatients and triage) to allow staff to have better oversight of all patients and where delays occurred. This would improve the oversight of risk.

We scored the service as 1. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The maternity services at the hospital consisted of an antenatal clinic, scheduled care, triage, labour ward, a theatre and procedure room, birthing centre, post-natal wards and a bereavement suite. There had been a considerable amount of work since our previous inspection to reconfigure the maternity unit footprint. Maternity services in the community was provided in community hubs, clinics and women’s homes.

There was 24/7 on-site security, window restrictors and swipe access, this was an improvement. The security team had expanded from 10 to 15 and monitored multiple CCTV cameras across the unit. However, we did observe an instance in the evening where visitors were able to tailgate other visitors on entry and exit of the unit. We were told partners staying overnight did not have to record their details and this posed a risk in the event of a fire or lockdown. We did not see evidence of a risk assessment.

The procedure room was still used for performing caesarean sections, it was not a theatre despite some improvements to the environment since our last inspection. Although the room had secure entry and ventilation airflow this was still not an appropriate environment for these procedures. Disposable curtains were hung outside of the doors to the room to allow more space inside. Surgical procedures being undertaken in a non-theatre environment and the risks around safety, infection and poor experience was one of the highest risks on the risk register with some control measures implemented. However, leaders acknowledged this was not a second operating theatre and work was ongoing to try and resolve this.

There were resuscitation trolleys kept on labour ward and antenatal unit. We found the resuscitation trolleys were complete, however, the tamper proof tags did not have reference numbers which meant there was no clear record of the tag changes.

The resus team had implemented a digital system for the checking of resuscitation equipment. However, this had not been fully effective in providing sufficient oversight and a new digital checklist was due to go live in March 2026. Until the digital system was in use, daily oversight was provided by the flow coordinator and daily check compliance was reported and monitored using a dashboard.

There was emergency equipment available in triage for hypoglycaemia (low blood sugar), eclampsia (life-threatening onset of seizures in a pregnant or recently postpartum woman), postpartum haemorrhage (heavy bleeding after childbirth) and birth. All items were in date however, the boxes containing medication were not tamper proof.

There was a lack of plug sockets where the resuscitaire was situated in triage for a blood oxygen monitor (SATS machine) in case of neonatal resuscitation. Staff used paper records to confirm checks of the resuscitaire had taken place. However, in triage the paper records were incomplete and did not provide assurance the resuscitaires had been checked as required. There was also a quick response (QR) code for staff to record the check electronically. We requested confirmation from the service which system they were using. The standard operating procedure dated January 2026 stated the daily check must be documented via the digital checklist dashboard and the resus team would monitor compliance. We saw evidence the daily check compliance was reported and monitored using a dashboard.

At our previous inspection we found the service did not have sufficient resuscitaires to meet the needs of the service. At this inspection we found this had been resolved. We saw they had a resusctitaire in each delivery area and there was enough capacity for twins.

Estates remained a challenge, we heard of water leaks in clinical areas impacting on patients and during our inspection there was a leak at reception located in the middle of the walkway. There was a lack of storage for equipment in most areas. For example, we saw cleaning tools and equipment stored in the area outside of the public toilets in triage. We observed equipment stored in the corridor between theatre and post-natal ward where a sign stated to keep the area clear. A storage trolley was seen in the corridor of post-natal ward (Willow ward), partially blocking the fire escape route. We raised this at the time of the inspection and the trolley was moved.

Needles were available on trolleys in areas where patients could access them, including triage and post-natal ward. The freezer used for meals for women on post-natal ward had ice build-up and it was unclear when this had last been defrosted, however the temperature was at the expected range. We observed mould on the ceiling in some areas and hazard tape was used to cover rips on the floor and to highlight pillars in the middle of rooms which provided structural support. There was a recurring theme from women we spoke with and who had fedback to the service about the environmental challenges. The post-natal ward was noisy and there was a lack of privacy.

At our previous inspection we found the service did not have environmental ligature risk assessments, in line with NHS national patient safety alerts issued in 2020. At this inspection we found risk assessments had been completed for the environment and individual risk assessments for women were undertaken.

There was an air conditioning unit available and the new layout in triage meant midwives had oversight of women. This was an improvement.

The service had a bereavement suite, which was in a quiet area, and the service had secured charity funds to modernise and refurbish this area. They had plans to work closely with the Maternity and Neonatal Voices Partnership to gain service user feedback and family wishes to inform this work.

Staff regularly checked birthing pool cleanliness and the service had a contract for legionella testing of the water supply and a standard operating procedure on how to clean the pool after use.

Breast milk was stored safely in temperature controlled environments and out of date milk was disposed of. This was an improvement from our previous inspection.

There was a dedicated operational manager for maternity to focus on estates. Previously, this role was joint with gynaecology. This would allow more time to dedicate to maternity estate issues.

In the community we observed women seeking asylum were housed in accommodation exclusively for single women or families. Midwives adapted their service to provide antenatal care for these women which was close to where they were living.

Most midwives working in the community were lone working. On-call activity was processed via labour ward coordinator and staff were expected to communicate and check-in and out. All staff had work mobile telephones, and when assessing for home birth they checked signal and Wi-Fi, using a landline if necessary.

We scored the service as 2. 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. They did not always work together well to provide safe care that met people’s individual needs.

There was not always enough obstetric medical workforce to support all rota activity. There were 12 consultants or associate specialist doctors on the consultant rota, and the service were actively recruiting to an obstetric post. There were 2 trainees not on the rota. We observed delays for women waiting to be seen and for their care to be reviewed in triage. There was not a dedicated doctor in triage after 5pm during the week or at weekends. We raised this during our inspection and the service increased doctor presence in triage to 8pm during the week and at weekends. There was a risk elective activity would be stood down and the ability to provide scheduled ward rounds would be compromised. There was no dedicated doctor cover in scheduled care. However, there was 24 hour emergency medical cover and twice daily ward rounds.

The service demonstrated improvements in workforce planning and oversight. A Birth Rate Plus report had been completed in November 2024, this was an improvement. A recommission of this report was planned following the reopening of Yeovil maternity unit. Midwifery and neonatal staffing was regularly reported to the Trust Board. Staffing levels were reported as largely stable, with good compliance for supernumerary labour ward coordinator cover and 1 to 1 care in labour.

The service had also reviewed leadership arrangements within specialist teams, merging some teams to create clearer leadership structures and more joined-up services. Leaders within the service group met formally each week to discuss operational pressures and workforce challenges. The service acknowledged ongoing recruitment challenges and was developing additional career progression opportunities to support recruitment and retention of midwives.

However, workforce challenges remained. Although vacancy levels were low against the funded establishment, the service identified a need for an additional 6 whole time equivalent registered midwives to maintain safe staffing due to increased activity and service reconfiguration. There was an overall funded establishment deficit of 16 whole time equivalent roles, mainly relating to specialist roles. Long term sickness absence continued to affect staffing resilience.

The service used bank and agency staff to support staffing, with minimum shift commitments, continued professional development requirements, and block booking of agency staff to support workforce planning. A consultation on rotational and multi-area working was underway to respond to patient acuity pressures, supported by preceptorship programmes to boost staff competency and confidence. These arrangements supported compliance with Maternity Incentive Scheme requirements relating to workforce and staffing systems between July and December 2025.

There had also been recent changes to community leadership arrangements. The community Matron role now covered Yeovil, Taunton, Bracken Birth Centre and the infant feeding team, whereas previously oversight had been site specific. There were 7 community leads. The service was undertaking a community review focused on caseloads, staffing levels, equity and workload. Leaders considered national expectations for community midwifery caseloads alongside local deprivation and safeguarding pressures. Monthly reviews were conducted to assess caseload weighting and identify where additional support was needed. Leaders recognised staffing distribution did not always reflect population need and consultation with staff was underway regarding changes to geographical working arrangements to ensure midwives were deployed more equitably.

There was a homebirth team which formally commenced in April 2025 and facilitated 80 homebirths in the first year. The service was available 24 hours a day 7 days a week and was staffed by 6 midwives.

Staff sickness continued to impact community teams. The service used bank staff to support gaps, recognising this was not a long‑term solution. Recruitment activity was ongoing, including additional staffing for Bracken Birth Centre following a staffing review and recruitment into inpatient vacancies to reduce the need to redeploy community midwives into inpatient services. The service was also developing closer working between community and inpatient teams, including shared roles across both areas to improve communication and integration of care.

The service closed once in the 12 months prior to our inspection. The midwifery led community birthing unit had been closed to births since 2023 due to the trust not being able to staff the unit safely.

At this inspection we found there had been some improvement in mandatory training compliance levels, but staff were not always up to date with their mandatory training. The trust target for compliance was 90% and the service was 79% compliant overall in January 2026. Records showed low compliance rates for some training modules, such as 44% in medicines management and 35% in medical devices competency assessment. Other areas of where compliance did not meet the target were saving babies lives at 70%, venous thromboembolism for medical staff at 70% and practical obstetric multi-professional training (PROMPT) at 83%. Fire training was due to be added to mandatory training from September 2026. We did not see evidence of how many staff were trained in newborn and infant physical examination (NIPE) or learning disabilities and autism. However, training was above the target of 90% for freedom to speak up, clinical waste management and pressure ulcer recognition.

Community teams had protected time for mandatory and professional development study weeks. There was community simulation training on PROMPT, and we were told this reviewed how community midwives maintained skills, particularly in relation to home birth provision. There were maternity support workers working under supervision with an allocated midwife for support.

There was a practice development and improvement lead midwife who developed training which was aligned to evidence based practice and incident themes.

The service had a flow coordinator midwifes. Flow coordinators were supernumerary and had oversight of the staffing, acuity, and capacity within the unit. They reviewed and adjusted staffing levels and skill mix daily according to the needs of the service.

The service completed ad hoc multidisciplinary simulation training, this included neonatal life support, missing baby, fire evacuation in theatre and post-partum haemorrhage (PPH) / major obstetric haemorrhage (MOH) in theatre. (PPH is bleeding after childbirth and MOH is life threatening bleeding after childbirth).

Newly qualified midwifes had an induction programme of 2 weeks in each area of the unit supernumerary, before going on rotation as part of staffing numbers.

We scored the service as 2. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We found the storage of hazardous substances was secure and staff adhered to IPC policies, which was an improvement. However, the service was situated in an old building that required numerous repairs and maintenance.

Hospital and community areas were mostly clean. However, we found the resuscitation trolley on antenatal ward was dusty. We observed a leak in the maternity entrance with a bucket to catch the water. Post-natal ward was a nightingale ward (a nightingale ward is a large, open-plan layout with multiple beds sharing a single space) which meant there was an increased IPC risk. We saw internal pipes were not boxed in which meant there were hard to clean areas making effective decontamination a challenge. On post-natal ward we observed old mildew in the grout of a patient shower, a cobweb hanging from a ceiling in an empty bed bay and mould patches on the ceiling. There was no signage about handwashing at sinks. However, we observed the cleaning down of a bedspace was fully stripped and surfaces wiped. Disposable curtains were used with dates recorded and patient led assessments of the care environment (PLACE) scored 100% for maternity for cleanliness in 2025.

Due to the use of the procedure room for surgical procedures, the trust had monitored infection rates post caesarean section since November 2025. During November and December 2025, 237 caesarean sections were undertaken, and 2 patients were readmitted with infections. All patients that had undergone a caesarean section were sent a follow up questionnaire at 30 days post procedure. A total of 9 women reported issues with their wounds, and these were classed as patient reported infections. As these were not always validated by a healthcare professional, they were not included in the infection rates. However, we were told these were monitored and should there be a significant number of patient-reported infections, this would trigger further action.

One of the birthing pools in the Bracken Birth Centre was out of use due to damage. The pool was due to be replaced because efforts at rectifying the problem had been unsuccessful. A new standard operating procedure had been produced to prevent the problem reoccurring. There were instructions on how to clean the pool including running the taps daily due to the risk of legionnaires. Since our inspection, we were told a new pool had been sourced and was in use.

We observed staff in the hospital and community setting adhered to infection control principles, including handwashing. Hand hygiene compliance showed 95% and above for January 2026 for hospital-based staff. However, community midwifery teams did not provide any data for hand hygiene audit for the same period. There had been challenges associated with the digital platform used to submit audit data. A review of the process was underway and revised approached was being developed.

We scored the service as 2. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning

We found medicines were stored safely. This was an improvement from our last inspection. However, there were variable standards of medicines governance, documentation, and oversight. While most staff demonstrated commitment, the systems designed to support safe and effective care were inconsistently applied.

Across Willow ward, we identified clear weaknesses in medicines safety processes. We observed stock with incomplete labelling, including a morphine oral solution sticker with an open date documented but no date of when to discard. There was not consistent evidence of daily or weekly Controlled Drugs stock checks. Staff on Willow ward were unclear about the management of FP10 prescriptions (an FP10 prescription is provided by either a GP, hospital doctor or midwife to enable a pregnant person to obtain free medication for any condition).

Fern ward demonstrated more structured medicines management, including daily Controlled Drug checks, as evidenced in the Controlled Drug register. However, the resuscitation trolley had no records kept of seals between each daily check. There were medication history gaps in patient medicines documentation; for example, 1 patient admitted with reduced fetal movements had no mention of drug history during triage.

The community maternity clinic showed inconsistent documentation related to medicines. In several cases, the medicines history was left blank rather than stating ‘none’, reducing reliability of clinical decision‑making. There were gaps in stock as ‘stock levels of medicines kept on site were not currently routinely monitored’.

Across all areas, pharmacy oversight was limited. Staff on Fern ward reported that no pharmacy technician or pharmacist attended but rather a porter from pharmacy came to replenish stock, and staff we spoke with did not know who the Controlled Drugs Accountable Officer was.

However, we observed dedicated staff and some examples of effective practice. Across Fern ward, allergy status and venous thromboembolism (VTE) assessments were consistent. (VTE is a serious, often preventable condition where blood clots form in the deep veins and can travel to the lungs). In the community, midwives demonstrated strong referral pathways such as escalating mental health concerns.