Gosport War Memorial 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, 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.

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.

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 Blake Birthing Centre in the 6 months prior in inspection.

We reviewed incident reporting for Blake Birthing Centre which showed 11 incidents reported in the 11 months prior to inspection, of these all were rated no harm.

There was minimal evidence regarding serious incidents at this site due to low activity (MLU with 10 deliveries in 18months), 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 people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor women’s safety. They did not always make sure there was continuity of care, including when women 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 if the women’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. Staff at the MLU maintained a record of women who did not give birth in their chosen place of birth which showed this occurred routinely in the 12 months prior to assessment.

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.

A Continuity of Carer (CoC) team, referred to as Juno, 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.

There was minimal evidence for intrapartum care on site due to low activity (MLU with 10 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 6 maternity records and found safeguarding assessments were routinely completed during antenatal contacts, with staff consistently asking safeguarding-related questions.

There was minimal patient record evidence on site due to low activity (MLU with 10 deliveries in 18 months), the majority of the information can be found in the (Main site) report.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks. Staff provided care to meet people’s needs that was safe.

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) which was called Juno. 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. This service 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. This reflected NHS England's ambition to improve outcomes for women and babies who experience the greatest risk of adverse outcomes.

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 Blake Maternity Centre, midwives made decisions to transfer with support from the labour ward lead midwife. The midwife from the birth 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.

In the 18 months prior to our inspection, 4 women labouring at Blake were transferred to the main trust site. The service advised that the majority of transfers were post birth and were largely due to post-partum haemorrhage & perineal suturing.

Of the 6 intrapartum care records we reviewed, where the woman had remained at the service, all postnatal checks had been completed.

There was minimal evidence of intrapartum care on site due to low activity (MLU with 10 deliveries in 18months), the majority of the information can be found in the (Main site) report.

We scored the service as 3. The evidence showed a good standard. The service routinely monitored women’s ’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The design of the environment followed national guidance. There was a waiting area for women and their families with appropriate seating and access to toilet and breastfeeding areas. The waiting area was in a room with ample seating and a receptionist. This meant that those attending could be seen at all times.

The service had enough suitable equipment to help them to safely care for women and babies. There was 1 birthing room with a birthing pool, an active birth swing and birthing aids. The labour room had ensuite bathroom facilities and curtains around the inner door area to provide confidentiality. Women could reach call bells in birthing rooms. There was also an infant radiant warmer, often referred to as a resuscitaire, for staff to perform essential care and newborn observations such as APGAR scoring.

The birthing suite was well designed and decorated to promote a calm birthing environment with ambient lighting. There were electronic tealights, sound systems with relaxing music, and a galaxy projector. The ensuite area had a shower with bath and was clean and well designed to ensure patient safety, with call bells showing a testing log. Seating for birth partners included a high back chair.

We checked a sample of electrical equipment and confirmed all items had evidence of a recent portable appliance testing (PAT) safety test. Women could reach call bells in birthing rooms.

Staff carried out safety checks of specialist equipment. However, we found instances where equipment was not checked in line with trust policy or national recommendations.

The post-partum haemorrhage (PPH) trolley had a weekly checklist, records showed weekly checks had been completed in full. The trolley was secure with security tags intact.

Within the birthing suite, the resuscitaire had some periods where daily checks had not been completed. In the 3 months prior to inspection there were 7 instances where this had not been checked. These instances fell on days where the service was operating. Resuscitation Council UK (RCUK) recommends that all emergency trolleys and equipment, including those for obstetric emergencies like postpartum haemorrhage (PPH), should be checked daily to ensure they are fully stocked, in-date, and functional. We saw no evidence that harms had come to women due to equipment checking. 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 a panel on the birthing pool which was loose and had an exposed screw thread. We raised this with local senior leaders and saw this was immediately rectified.

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. Blake birthing 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 care 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, pre-existing 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 trust 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 Blake Maternity Centre specifically. This meant we were unable to identify compliance levels for staff working at Blake Maternity Centre or determine whether there were any specific training gaps or areas requiring improvement within that location.

There was minimal evidence on site regarding staffing as it relates to intrapartum care levels due to low activity (MLU with 10 deliveries in 18 months), the majority of the information can be found in the (Main site) report.

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

All areas in maternity were visibly clean. Cleaning records were up to date and showed all areas were cleaned regularly.

Staff followed infection prevention and control principles and used personal protective equipment correctly (PPE). Staff were bare below the elbow, and we observed them cleaning their hands with alcohol-based hand gel. Staff prompted all visitors to clean their hands on entering the department. And we saw visitors using these throughout our assessment. There was sufficient supply of PPE such as gloves, masks and aprons.

Housekeeping was provided by the trust who maintained and owned the hospital site. Bathrooms and toilets were clean and there were laminated posters explaining hand washing technique. Privacy curtains were clean and labelled with their replacement date.

In the birthing suite, equipment that was not routinely used was covered in protective sheets and we saw that equipment underneath was well maintained. In clinic rooms we saw that staff cleaned clinical equipment after patient contact. However, ‘I am clean’ stickers were not used on some equipment in rooms that were not in use on the day. This meant staff may not know when equipment used on women and babies was last cleaned and posed an infection control risk.

Staff were familiar with cleaning policies for the labour/birthing pools and cleaning records were up-to date and demonstrated all areas were cleaned regularly.

Staff adhered to infection control principles, including handwashing. We saw that all staff were bare below the elbow and performed handwashing when indicated, in line with trust policy. Monthly hand hygiene audits were undertaken and these showed full compliance for 4 months prior to inspection.

Staff managed clinical waste in accordance with the trust policy. There were clean and dirty sluice areas, and these were secure. Processes were compliant with DHSC health technical memorandum (HTM) 07/01 in relation to the safe management and disposal of healthcare waste. Fridge temperatures were monitored to ensure their contents, such as medicines, were safe for use.

Staff and signage prompted all visitors to clean their hands on entering the department. And we saw visitors using these throughout our assessment. There was sufficient supply of PPE such as gloves, masks and aprons.

Employers are legally required to assess risks from sharps injuries and put appropriate control measures in place. Staff disposed of and used appropriate systems for the management of sharps. All sharps’ bins and sharps’ practice we observed were compliant with Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.

We saw evidence that testing of water outlets had identified the need for daily flushing of taps. All rooms had signage to document this had taken place and these were completed in full throughout.

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 involve 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) were in place to allow 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 PGD’s 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.