St Mary's Hospital

On this page

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

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

This meant some aspects of the service were not always safe and they did not demonstrate they were assured about safety. This mean there was an increased risk that people could be harmed.

The service was in continued breach of Regulation 12 for Safeguarding Training, with staff not completing mandatory training.

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 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.

Staff knew what incidents to report, raised concerns and reported incidents and near misses in line with the trust policy. Staff reported incidents that they should report through the trust level incident reporting tool.

Staff raised concerns and reported incidents and near misses in line with trust policy. The service used national risk tools, such as the Patient Safety Incident Response Framework (PSIRF) and a Perinatal Quality, Safety Risk Framework to review and monitor risk. There had been no adverse events that are specific to this service in the 6 months prior to inspection. Senior leaders told us that staff would be debriefed and supported staff after any serious incident and staff confirmed this. Staff understood the duty of candour.

Senior leaders shared learning about never events with their staff and learning from incidents across the trust. The maternity centre had no never events in the 18 months prior to inspection. Outcomes and themes of incidents was communicated to all staff through daily safety huddles, handovers and via emails.

Senior leaders investigated incidents thoroughly. Women and their families were involved in these investigations. Parents were encouraged to give additional information and feedback when investigations happened, we were told parents were offered both a copy of the report and meeting to discuss the findings on completion. Staff received feedback from investigation of incidents, both at this location and those within the wider trust maternity team.

Staff reported incidents of Perinatal Mortality to Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries (MBRRACE). The aim of MBRRACE is to support objective, robust and standardised local reviews of care when babies die. We saw evidence that showed that trust staff were familiar with how to report perinatal mortality when needed. The data showed there had been no incidents requiring MBRRACE reporting at Portsmouth Maternity Centre in the 6 months prior to inspection.

We reviewed incident reporting for Portsmouth Maternity Centre which showed 13 incidents reported in the 11 months prior to inspection, of these 10 were rated no harm and 3 low harm.

There was minimal evidence regarding serious incidents at this site due to low activity (MLU with 12 deliveries in 18 months), the majority of the information can be found in the (Main site) report.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with women 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.

Women were not always supported to give birth in a place they had chosen. The service’s referral and admission processes ensured that all essential information about the woman was received to determine whether the woman's needs could safely be met. Booking midwives met with women to discuss their maternity journey and intended birthing plans. Women were supported to make a choice surrounding their place of birth based on their personal views and health. However, operational pressures at the main hospital meant women’s choices often could not be supported.

Staff at this service told us women in labour, who were considered to be low risk, were often advised by the maternity triage line to attend the acute hospital rather than smaller midwife run units. The trust told us this was due to staffing and acuity pressures at the main hospital which prevented the release of staff to midwife led units (MLU). The trust also did not have on call staffing provision for low-risk births.

Community teams worked with local services, such as GPs and support services to support the ongoing health and wellbeing of the mother and baby.

Midwives followed the standard admission process for all women in established labour, regardless of place of birth. The trust operated a maternity triage line outside of the trust and was a single point of access for all maternity referrals for 4 local NHS trusts within the local maternity and neonatal systems (LMNS). The CQC national survey question for maternity telephone triage “Thinking about the last time you contacted the telephone triage line, did you feel that you got the advice you needed?” scored broadly in line with the national average.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care within the service during their pregnancy. Community midwives and health visitors supported women, and their families post discharge and liaised with other healthcare providers.

Continuity of Carer (CoC) teams (Athena and Hera) provided dedicated care to women who were vulnerable women to ensure they had access and support from the same midwife and small team throughout their pregnancy. CoC midwives provided 24‑hour, 7‑day on‑call intrapartum care, this ensured women received care from a known midwife at their chosen place of birth, including home, community, or hospital settings. Only community midwives working within CoC teams participated in on‑call arrangements to ensure they were present during labour for the women the team supported.

Staff at this service told us women in labour were frequently advised by the maternity triage line to attend the acute hospital rather than smaller midwife run units. This meant women did not always give birth in the place they had chosen. The service did not monitor data regarding women being declined their chosen place of birth but had developed an action plan to do so following our assessment.

Between October 2025 to March 2026 there were 17 cases where women were transferred from the main trust site to a neighbouring trust for their induction of labour due to operational pressures and delays within the service. These delays were discussed during the regional maternity ‘hot call’, where women were transferred to another neighbouring trust for their IOL if it was appropriate and safe to do so. An increase in moderate harm incidents during December 2025 were attributed to high activity and acuity alongside several temporary unit closures at the main trust site and delays in care.

There was minimal evidence for intrapartum care on site due to low activity (MLU with 12 deliveries in 18 months), the majority of the information can be found in the (Main site) report.

The evidence showed significant shortfalls. The service did not ensure that staff completed safeguarding training to inform their role. This meant we had limited assurance that they consistently shared concerns quickly and appropriately to improve people’s lives, live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The service could not demonstrate that all staff had completed and remained up to date with safeguarding children level 3 training. Compliance rates were below the trust target across several staff groups, which meant senior leaders could not be assured that staff had the current knowledge and skills required to identify, respond to and escalate safeguarding concerns appropriately. Medical and anaesthetic staff had particularly low compliance, at 29%, while maternity support workers were 78.5% compliant and midwives were 80.3% compliant.

The service also could not provide assurance that staff regularly participated in baby abduction drills. Staff were unable to tell us when the last baby abduction drill had taken place. Regular drills are important to ensure staff understand their responsibilities and can respond promptly and effectively in the event of an attempted baby abduction. Without evidence of regular testing and training, senior leaders could not be assured staff would be confident and competent to manage such an incident.

Staff knew how to identify safeguarding concerns and understood the process for making referrals and escalating concerns when required. Staff gave examples of safeguarding referrals they had made and described actions taken in accordance with trust policies. They also demonstrated an understanding of how to protect women from harassment and discrimination, including those with protected characteristics under the Equality Act. Specialist continuity of carer midwifery teams supported women in vulnerable circumstances to access care and support throughout their pregnancy.

Staff followed safe arrangements for children visiting the service. Women attending appointments with children were advised to supervise them at all times, and clear signage was displayed throughout waiting areas to reinforce this message.

We reviewed 4 women’s maternity records which showed safeguarding questions were not routinely asked during each antenatal contact. This meant we were not assured that women were consistently safeguarded by the service.

There was minimal patient record evidence on site due to low activity (MLU with 12 deliveries in 18 months), the majority of the information can be found in the (Main site) report.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with women to understand and manage risks. Staff did not always provide care to meet women’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff completed risk assessments for each woman at maternity appointments. Staff did this using a recognised tool and reviewed these assessments continually throughout the pregnancy. Care records we reviewed supported this. Risk assessments covered a wide range of factors, including fetal growth, carbon monoxide monitoring, and venous thrombus embolism (VTE).

Staff communicated with women so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties.

Staff shared key information to keep women safe when handing over their care to others. The digital system used for recording risk assessments meant that all relevant staff could view risk assessments from all previous interactions throughout a woman’s pregnancy.

When a mother was identified as having increased vulnerability, due to socioeconomic factors, they were allocated to the Continuity of Carer (CoC) teams which were called Athena and Hera. The CoC team had a caseload which included a diverse population of women with mixed levels of need. Women previously allocated to this team, or who had subsequent pregnancies could request the same team to manage their care. This ensured continuity and consistency with regard to ongoing or previous safeguarding risk. The CoC team could also be requested by a mother who had previously had a traumatic birth experience.

Women under the CoC team had all of their appointments, when possible, with the same named midwife, or from a small team of 8 people. Women being cared for by the team were given opportunities to meet all the team members during antenatal appointments, parent education classes, antenatal coffee mornings, targeted workshop groups and “Meet the Midwife” sessions. Midwives from this team told us how they explained the process to women, who were grateful for the continuous support received. Staff were proud of the work they did to support women, and the connection working in this team gave them.

Women who were considered low risk, were able to request to give birth at the MLU or their own home. Births at the MLU or at a woman’s home were attended solely by midwives. Those with additional risks would be advised to deliver their baby at the consultant led unit at the main trust site. Women who chose to birth outside of guidance attended the birth options clinic to discuss risks and available options with a Consultant Midwife and develop a personalised birth plan together.

If an obstetric review was needed for someone birthing or postnatally at Portsmouth Maternity Centre (PMC), midwives made decisions to transfer with support from the labour ward lead midwife. The midwife from the maternity centre travelled with the mother to the main hospital to support their ongoing care. Staff told us women were aware that if a problem arose during labour, then they may be transferred to the main hospital site. Women were aware of how long it may take to transfer to the main site if required and on average it took 15 minutes from the time of transfer from the maternity centre to the main hospital site. The service advised they undertook joint training with the ambulance service to support education and effective care transfers.

There were 13 women transferred to the main hospital in the 18 months prior to our inspection. The service advised that pre-birth transfers were significantly more common where first-time mothers are more likely to transfer due to longer or more complex labour journeys. Transfers were commonly due to delayed first stage of labour (50%) followed by concerns with foetal movements and meconium.

Of the 4 intrapartum care records we reviewed, where the woman remained at PMC, 1 did not have newborn checks fully documented.

There was minimal evidence of intrapartum care on site due to low activity (MLU with 12 deliveries in 18 months), the majority of the information can be found in the (Main site) report.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

We identified several environmental issues relating to equipment safety, emergency preparedness, environmental maintenance. Emergency equipment was not always checked in line with trust policy. The post-partum haemorrhage (PPH) trolley was subject to a weekly checking process; however, records showed gaps in completion. In the 6 months prior to inspection, there were 4 occasions where checks had not been completed within 7 days, including 2 occasions where the interval exceeded 13 days. These periods occurred while the service was operational. The PPH trolley was also not secured with a tamper-evident seal. This meant the service could not be assured that unauthorised or unrecorded access would be identified, creating a risk that equipment or consumables could be removed, altered or not replaced. In addition, it contained expired items and sterile gloves containing latex, presenting a potential risk of anaphylaxis if used during an emergency. As a result, staff could not be fully assured that the trolley remained complete and ready for immediate use in an emergency.

We also found concerns regarding newborn emergency equipment. The infant radiant warmer (resuscitaire), used for newborn observations and essential care, had not consistently undergone the required daily checks. During the 3 months prior to inspection, there were 9 occasions where checks had not been completed. Although we found no evidence that women or babies had come to harm as a result of these omissions, the gaps meant the service could not be assured that equipment was always ready for use. Following the inspection, the trust told us that all Maternity Support Worker (MSW) checklists had been reviewed at the Clinical Leads Meeting in April 2026 to ensure alignment with trust policy. Resuscitation Council UK guidance recommends that emergency trolleys are checked daily to ensure equipment is complete, in date and ready for use.

There were 2 birthing rooms, 1 with a birthing pool and 1 with an active birth swing. Both labour rooms had ensuite bathroom facilities, privacy curtains around the inner door area, and accessible call bells for women. Within 1 birthing room, there was no telephone available for staff to summon assistance. This was not in line with the trust’s risk escalation policy, which required use of the room telephone during emergencies, and could delay emergency response. In addition, the emergency contact information displayed on a noticeboard contained 3 separate sets of instructions with differing contact numbers. This created a risk of confusion for staff unfamiliar with the environment, including student midwives, and could contribute to delays in obtaining support.

We identified environmental issues that affected the quality and maintenance of facilities. Seating provided for birthing partners consisted of basic low-rise chairs more suited to short-term waiting areas than prolonged use during labour. The birthing pool had visible limescale and water staining around the tap and plug areas. Bathrooms serving both labour rooms showed ingrained limescale and areas of damaged flooring. Following the inspection, the trust advised that a previous deep clean had not fully resolved these issues and that replacement works would be undertaken.

We also found environmental risks relating to health and safety. Doors giving access to areas containing pipework and electrical cabling had been left unlocked, potentially placing staff and members of the public at risk. Maintenance services were provided by the host NHS trust and staff submitted requests through an internal reporting system; however, no local log was maintained to provide oversight of reported issues and actions taken. This limited local and senior leaders’ ability to monitor outstanding maintenance concerns. Following our inspection the trust told us that review of all safety checklists took place in April 2026 to ensure alignment with Trust policy.

There was also minimal equipment to ensure the rooms did not feel too clinical. We saw that nearly all battery-operated tea lights did not function and there were no abilities to dim lighting. There were also no ambient lighting, such as galaxy projectors, that were seen in other maternity settings run by the trust. In addition, we found items stored within pathology freezers that were not appropriate for the area. Local leaders acted immediately and removed these items during the inspection.

Despite these concerns, the service generally had sufficient equipment and facilities to support the safe care and treatment of women and babies. The environment was designed in line with national guidance, and a sample of electrical equipment showed evidence of current portable appliance testing (PAT) safety checks. The department also included a waiting area for women and families, with appropriate seating, toilet facilities and access to breastfeeding areas. Clinical areas were accessed through secure doors that restricted entry unless accompanied by staff, and photographs displaying staff names and roles helped women identify the team involved in their care.

We scored the service as 2. The evidence showed some shortfalls. 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. This meant they did not always work to provide safe care that met people’s individual needs.

The service was staffed solely to meet the needs of women attending for planned attendances such as antenatal and post-natal clinics. Portsmouth maternity centre hosted multiple clinics, and midwives flexed their activity to provide clinic and clinical support where required. The Operational Coordinator (Op Co) and lead Midwife actively coordinated staffing and monitored activity and acuity to ensure staff levels met the needs for daily activity. The Athena, Juno and Hera continuity of carer team were based across 2 Midwife led units, this included Portsmouth Maternity Centre and Blake Maternity Centre.

However, staffing pressures at the main site directly impacted the MLU service’s ability to consistently support women’s choices as there were not always staff available to be released from the main site to midwife led units. In operational hours (8am-8pm) staffing was coordinated via the Operational Coordinator (Op Co) and Maternity Link Midwife.

For a woman to give birth at the MLU during operational hours, 1 midwife would be requested to attend from the main maternity unit to the MLU. If the main maternity site could not release a midwife due to onsite low staffing levels, then the 2 midwives would need to be staffed by the community teams. However, this was not always possible, due to low community staffing levels, ongoing maternity clinics, appointments and home visits.

The service did not operate on‑call staffing arrangements for MLUs. Between 20:00 and 08:00, the service required a minimum of 2 midwives to be released from the main hospital site to ensure safe care. Staffing arrangements for women in labour was centrally monitored by the trust. We also spoke to staff at the main hospital site who confirmed they were not easily released due to the patient workload already allocated to them at the main hospital site. This meant that staffing shortages at the main hospital site directly impacted on women who wanted to give birth at the service.

Following our inspection, we requested mandatory training data from the trust. The information provided demonstrated overall compliance with mandatory training requirements; however, it did not provide sufficient detail to show compliance across all individual training subjects and staff groups. In addition, the data was reported at service level and was not location specific.

The trust did provide multidisciplinary (MDT) skills training compliance data against a target of 90%. Data showed high levels of compliance amongst most staff groups. Compliance rates were reported as 88% and 94% for consultant obstetricians, 90% for resident obstetricians, 90% for consultant anaesthetists, 92% for resident anaesthetists, 97% and 98% for registered midwives, and 97% and 98% for maternity support workers.

However, while this provided assurance that compliance with MDT skills training was generally good across the maternity service, the data did not provide sufficient detail to demonstrate compliance in specific mandatory training subjects or identify whether there were any risks at Portsmouth Maternity Centre specifically. This meant we were unable to identify compliance levels for staff working at Portsmouth Maternity Centre or determine whether there were any specific training gaps or areas requiring improvement within that location.

As a result, we could not fully determine whether all staff working at Portsmouth Maternity Centre had completed the mandatory training required to carry out their roles safely and effectively, or whether senior leaders had adequate oversight of training compliance at a local level to identify and address areas for improvement.

There was minimal evidence on site regarding staffing levels as it relates to intrapartum care levels due to low activity (MLU with 12 deliveries in 18 months), the majority of the information can be found in the (Main site) report.

We scored the service as 2. The evidence showed some shortfalls. 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.

Within the birthing environment, we found a number of cleanliness and maintenance concerns. Seating in birthing rooms showed visible damage and a build-up of dirt on chair legs. The birthing pool had visible water staining and limescale despite records indicating it had been cleaned recently. In addition, the cleaning policy displayed beside the pool did not reflect current guidance and was not the most recent version. Ensuite bathrooms in labour rooms showed visible limescale build-up on flooring, shower heads and raised floor guards. Shower stools also had visible dirt and limescale accumulation on their rubber feet. Following our inspection the trust advised that a deep cleaning of these areas had been performed but had not been effective in removing the limescale, therefore flooring was being replaced.

In clinic rooms, some equipment did not display ‘I am clean’ stickers. This meant staff could not be assured when equipment used for women and babies had last been cleaned, creating a potential infection prevention and control risk. We also observed dust beneath protective covers on infrequently used equipment, including newborn cots in both labour rooms, resuscitaires and the post-partum haemorrhage trolley. This suggested equipment may have been uncovered for checks and not adequately cleaned before coverings were placed back over equipment.

Environmental cleaning was not always consistent. Although cleaning records were up to date and indicated that areas were cleaned regularly, we found bins in rooms that had not been emptied overnight, despite records showing this had been completed. We raised this with local leaders, who addressed the issue with housekeeping staff during the inspection.

In addition, we found that 1 sluice was not functional and this had not been reported. This meant the trust could not be assured that faults affecting infection prevention and control processes were being identified and escalated appropriately.

Despite these findings, clinical areas were mostly clean, suitably furnished and generally well maintained.

Staff demonstrated good hand hygiene. We observed staff cleaning clinical equipment after patient contact and adhering to hand hygiene requirements in line with trust policy. All staff were bare below the elbows and performed hand hygiene when indicated. Monthly hand hygiene audits showed full compliance in 3 of the 4 months preceding inspection, and senior leaders told us that any areas for improvement would be addressed with individual staff members. Staff and signage encouraged visitors to clean their hands on entering the department, and we observed visitors doing so throughout the inspection. There was also an adequate supply of personal protective equipment (PPE), including gloves, masks and aprons.

Staff managed clinical waste in accordance with trust policy. Clean and dirty sluice areas were secure, and waste management processes complied with DHSC Health Technical Memorandum (HTM) 07-01 requirements for the safe management and disposal of healthcare waste. Fridge temperatures were monitored appropriately to ensure medicines and other stored items remained safe for use.

Sharps were managed safely. Staff used appropriate systems for the handling and disposal of sharps, and all sharps bins and sharps practices observed were compliant with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.

We also saw evidence that water outlet testing had identified the need for daily flushing of taps. Following the inspection, the host NHS trust provided records demonstrating that this activity had been completed as required.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met women’s needs, capacities and preferences. They involved people in planning, including when changes happen.

Staff stored and managed all medicines and prescribing documents safely. The location did not hold controlled drugs; this was in line with the low-risk nature of births that could occur there. Medicine was stored at appropriate temperatures, and fridge temperatures were monitored.

Staff followed systems and processes to prescribe and administer medicines safely. When medicines were dispensed, records were completed in full within patient notes and internal records. Staff mostly followed good practice in medicines management and did it in line with national guidance.

The service had a medicine administration guideline for midwives. Midwives had access to the full list of midwives’ exemptions, so they were clear about administering within their remit.

The Maternity service social media page had a dedicated video which discussed the options for pain relief in labour. There was also signposting to a national website produced by the Obstetric Anaesthetists' Association (OAA) which provided expert, unbiased information on pain relief choices during labour for expectant parents

The service did not complete routine prescription audits. The service reported that an annual maternity service-level review of medications administered by midwives was due. Patient Group Directions (PGDs) allowed for appropriately trained staff to administer medicines within a specific framework. We reviewed the PGDs for medicines administered by midwives at the birthing centre and saw that these were in date. This had been previously completed alongside the pharmacy team.

However, an annual audit of medicines prescribed under PGDs had not been undertaken in the last 12 months. This was not in line with national guidance which states that should be audited as part of an organisation’s medicines audit programme. Annual audits on PGDs should be performed to inform whether a PGD remains the most suitable mechanism, is still required and helps organisations ensure PGDs use is appropriate.

In addition to this we found a small number of expired medicines which were highlighted to local leaders and removed immediately.