Croydon University Hospital

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• 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 good. At this assessment, the rating has changed 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 triage, incidents, risk assessments, records, safeguarding, equipment, staffing, medicines, appraisals, mandatory training and infection prevention and control.

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 had a proactive and positive culture, based on openness and honesty. However, incidents were not always reported, degree of harm classed correctly and managed in a timely manner.

The trust did not always correctly classify the level of harm, which hindered its ability to effectively manage the service, reflect harm sustained by service users, and improve safety. We found persistent themes of major obstetric haemorrhage and third-degree tears categorised at a less severe harm rating than appropriate. Post assessment, we raised our concern with the trust around the classification of incidents. In response they told us these incidents were reviewed at weekly incident review meeting to identify the exact details and grading of incident, this would then determine if the incidents classification should be downgraded. However, we were not provided evidence to support this and review the impact.

The service had an incident reporting system that was accessible to multidisciplinary staff. Staff knew what incidents to report and how to report them. However, staff did not always raise concerns and report incidents and near misses in line with trust policy. For example, the induction of labour (IOL) audit revealed that 87% of IOLs triggered a red flag event, but staff did not report these as safety incidents. Some staff members told us they did not always report all incidents due to workload and high acuity in the unit.

From September 2024 to July 2025, 1076 incidents were reported through the incident reporting system for the maternity service. The service had no ‘never’ events on any wards in the last 12 months. The top incidents reported relating to maternity care were; admission to the neonatal unit, and staffing. The service reported that each incident was reviewed daily by the quality and safety midwives, to identify incidents that required immediate review, investigation, action and closure. They also determined whether a full investigation was required or whether a local review would suffice to identify themes and learning opportunities.

At the time of our assessment, the service had 121 incidents open and of these, 37 were classed as overdue. Data showed that 14 of the overdue incidents were awaiting investigation. This was due to the requirement of a Patient Safety Incident Investigation (PSII) or perinatal mortality review tool (PMRT) which are internal investigations and require extended time to complete”. The trust advised that they were prioritising the closure of the overdue incidents and had set a trajectory to reduce them to fewer than 20 by the end of October 2025. The trust provided evidence which showed the incidents backlog was prioritised and there was reduced number of overdue incidents. The trust advised and we observed that all open and overdue incidents were monitored weekly at the maternity incidents review meeting and allocated to matrons and clinical leads. This had improved the number of open and overdue incidents in recent months according to staff.

From September 2024 to July 2025, the service referred 6 incidents for external review to Maternity and Newborn Safety Investigations (MNSI). Four referrals were accepted, 1 was rejected, and 1 was pending acceptance. Referrals was in line with national guidance and related to active cooling, maternal death and intrapartum stillbirth cases.

Managers reviewed incidents regularly and used an incident tracker to identify and monitor potential immediate actions. Managers investigated incidents thoroughly and involved women and their families in these investigations.

Staff received feedback from the investigation of incidents, both internal and external to the service. Learning from incidents was also discussed at the handover meeting and at governance and staff meetings. Managers shared learning with their staff about safety incidents and complaints, resulting in changes that improve care for others. This included an improved escalation process in triage after external incident investigations. Key messages from learning from incidents and complaints were shared at handovers and monthly newsletters. Recent key messages included documenting swabs during emergencies, referring women following third- and fourth-degree tears, and issuing safety alerts on heel warming. Staff were debriefed and received support by senior managers and governance team after an adverse incident.

Women and their families could give feedback on the service and their treatment, and staff supported them in doing so. Staff views were listened to and considered. Examples of improvements made to the service following feedback received included parent education and training on pelvic health, preceptee midwives' perinatal equity training, home breast pump loan scheme and updated self-referral booking form. Staff told us these improvements have improved women’s experience, staff competencies and service delivery.

The service completed the Patient Safety Incident Response Framework (PSIRF) pilot learning peer review in October 2024, which was the first for the Southwest London system. The service was one of the early adopters of the PSIRF framework and utilisation of the learning response tool. The review found that the service was proactive in implementing the framework, with strong collaboration and a focus on learning. The review also found there was good capacity for incident investigation, hot debriefs and support for staff following an incident. The challenges identified were staffing, staff training, the psychological impact on incident investigators, incident report writing, and the need for obstetric support. The service had an action plan in place to address these challenges. For example, the service had improved staffing capacity and provided training for staff in incident investigation.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation when things went wrong. The duty of candour data was reviewed weekly at various governance meetings by senior leaders. From October 2024 to August 2025, 13 incidents required duty of candour, and the service achieved 100% compliance on stage 1 and stage 2 at the time of the assessment. This meant we were assured that the service was creating a culture of transparency, trust, and accountability in a timely manner.

We scored the service as 1. The evidence showed significant shortfalls. The service did not establish and maintain safe systems of care in maternity triage, the maternity day assessment unit, and the induction of labour. They did not manage or monitor people’s safety.

The service did not operate an effective triage process in managing the telephone and in-person triage to ensure the safety of women and babies. Women could not always access timely telephone advice and support. This meant women were at risk of harm due to delays in accessing timely advice and support from a suitably qualified member of staff.

The service did not have a dedicated midwife (or suitably trained member of staff) covering the maternity triage telephone line. This did not meet the Royal College of Obstetrics and Gynaecology (RCOG) Good Practice Paper No. 17, which recommends confidential triage by a dedicated midwife in a separate space. We observed a telephone in the main triage area, staffed by midwives who were also working clinically in the in-person triage area. Due to the high activity in the triage area, we found that telephone calls were not always answered. This raised concerns about the midwife's capacity to manage triage calls, conduct risk assessments and maintain records, particularly during high-acuity periods.

Staff did not always answer the triage telephone line, provide adequate advice to women or escalate issues to senior staff in a timely manner. Data showed poor compliance and high rates of call waiting and abandonment in the telephone triage audit. The January to August 2025 telephone triage audit, demonstrated that 27,686 calls were received, with only 47% of calls answered, 27.4% of calls were abandoned, and 25.6% were missed. The service did not take action or have improvement plans in place to address areas of poor compliance. There was a lack of oversight, understanding, and mitigation in place to prevent the delays women experienced in accessing maternity triage, where they were assessed, supported, and prioritised by a suitable, qualified member of staff. This increased the risk of avoidable harm to women and babies.

It was unclear from our discussions with staff whether a risk assessment had been carried out regarding the lack of a dedicated triage telephone line and the absence of a midwife. The triage guideline stated that the telephone line could be answered by either the triage midwives or the maternity support worker. This was not in line with the RCOG triage good practice paper. During the assessment, we were informed that the service had plans to relocate the triage to a new area; however, we were not provided with a timeframe for this, nor informed whether a business case had been approved to implement this change. Staff told us the service planned to implement a new voicemail system to direct women to maternity services if the triage telephone line was busy. However, there was no timescale on when the new voicemail would be implemented. We raised our concerns with the trust, and following our assessment, we were informed that a dedicated maternity telephone helpline, which was located away from maternity triage, was implemented on 26 November 2025. Weekly triage meetings had been introduced to monitor the implementation of the helpline and the progress of actions, benchmarked against the RCOG recommendations. The trust did not provide evidence of these changes, and we have not reviewed the impact of the changes.

The in-person triage did not have dedicated obstetric cover. It was covered by an on-call registrar and a resident doctor who also covered other maternity areas such as the day assessment unit and the antenatal ward. Staff told us the registrar and resident doctors were mostly absent at the required time of the day they were meant to cover triage. Midwifery and obstetric staff told us some consultants felt it was not their role to cover triage, and this impacted the timely review of women by obstetric staff. Although the maternity service had implemented a triage tool to assess women presenting to the unit with pregnancy related concerns, the medical and midwifery staff were not in line with the trust and national guidance. This has resulted in self-discharge of women from triage and risk of harm to women and babies from the incident data reviewed and feedback received from women. Following our assessment, the trust reported that a business case for triage obstetric cover would be presented to the trust board in January 2026.

We observed high activity and breaches of the 15-minute triage initial assessment of some women during our assessment. This was following the temporary redeployment of a triage midwife to the labour ward. This meant there was 1 midwife covering the functions of the in person and telephone triage for hours, which was not in line with the trust triage guideline. We observed the single triage midwife completing the initial assessment of a woman who was in the waiting area without her being present. This raised concerns about the correct prioritisation and assessment processes by staff during periods of high acuity. Senior staff told us the midwife redeployed to the labour ward had later returned to triage in the afternoon. However, following our assessment, we received conflicting information informing us that the midwife was not redeployed to triage.

Women's notes were not always fully comprehensive; however, records were stored securely, and all staff could access them easily. Midwifery staff did not maintain accurate, contemporaneous and complete records of risk assessments and care provided for women in triage. Similarly, the timings of medical reviews were not always clearly documented by doctors, which raised concerns about contemporaneous record keeping and the accuracy of audit data. The January to August 2025 triage audit showed that only 68% of women assessed by midwives had complete documentation, and 41% of women's records lacked documentation of the time they were seen by doctors. Midwives informed us that doctors often fail to complete this, and the timings may be entered onto the records retrospectively by the midwifery team if they are less busy.

The triage audit also showed that 82.1% of women were seen by a midwife within 15 minutes of arrival, compared to the target of 85%. The result showed that 22% of women were not reviewed by a clinician within the expected timeframe, in line with the red, amber, green (RAG) rating approach. This posed a safety risk to women and babies due to delays in accessing timely advice and support from doctors. The audit did not include what the service did differently from the previous month to address areas of concern, drive improvement, and increase the compliance rate. There was no associated action plan with the audit, so we were unable to assess if there was evidence of improvement. Following our assessment, the trust told us that the triage tool templates in the electronic record system had been updated to be more user-friendly and to support completion. We have not reviewed the impact of this change. The service had scheduled follow-up audits from January 2026 onwards to monitor documentation.

Staff told us there were high referrals of women for maternity triage to and from the main ED, resulting in delays in pregnant women receiving safe care and treatment. The triage audit showed high referrals from the main ED to maternity triage, indicating that women did not receive sufficient or comprehensive communication during booking and community care about whom to contact if they were concerned.

The July and August 2025 triage audits showed that unwell or other was the most common cause of attendance of women to triage. The result showed that 28% women attended triage due to being unwell, and of which 47% of these women were referred from the emergency department (ED) and community midwives. The triage guideline included an inclusion and exclusion criteria; however, it was not clear on what conditions should be referred to the ED and did not include the midwifery pathways. This raised concerns that the high referral to ED might be related to a lack of medical staff cover in the maternity triage. This posed a safety risk to women and babies due to delays in assessment and accessing timely advice and support from doctors. Post assessment, the trust provided us with the result of an in-depth retrospective audit of all women who attended the emergency department (ED) in August 2025. The result showed 1.3% of women were referred to maternity triage from ED, and whilst 0.6% women were transferred to ED from the maternity triage.

The triage audit data provided by the trust showed that maternity triage was seeing high numbers of women for clinical reasons (unwell/other) that should have been addressed in the maternity day assessment unit (DAU). At the time of our onsite assessment, DAU was staffed by a midwife and maternity support worker, which was not adequate, did not always meet the increased demand in the service, increased staff workload and increased the acuity in triage.

The April to September 2025 DAU audit result showed that blood pressure monitoring was the most common indication for women attending representing 42% of visits. This was followed by iron treatment (17%), urine test monitoring (10%) and obstetric pregnancy liver disorder assessments (10%). The audit found 100% compliance with the monitoring frequency guidance and with the actioning of escalations when indicated. However, the service did not monitor if women were seen within their appointment time and if there were any delays.

There were delays in access for induction of labour (IOL). Staff told us, that there were significant delays in the induction of labour process due to high labour ward activity, no available beds and staffing. The June to August 2025 IOL audit result showed that 87% of IOLs triggered a red flag event, and 61% of women experienced a delay of more than 4 hours between admission for induction of labour and the beginning of the process. 37% of women experienced a delay of 4 hours between the decision to transfer to the labour ward and the actual transfer. The service had an action plan in place, and the team planned to initiate an IOL quality improvement (QI) project to address delays in the IOL process, improve the booking process, enhance capacity management, and address staff workload. However, this had not been fully implemented and posed a risk because delays could result in a poor outcome for women and babies. Post assessment, the trust told us the QI project had been launched, and an RAG rating IOL tool and sticker had been developed, which was going through their approval process and would be launched in February 2026. A patient group directive (PGD) for an induced labour medicine had been written and was going through the approval process which will enable midwives to administer the medicine for women with a green RAG rating to reduce delays in starting IOL. However, all these changes occurred after our assessments and we have not been able to assess the impact of these improvements.

Staff completed risk assessments prior to discharging women into the community and made sure third-party organisations were informed of the discharge. Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.

The service provided transitional care for babies who required additional care or extra monitoring to stay with their mothers rather than in a neonatal unit. This helped improve parent-baby bonding and reduce hospital stays.

Staff followed up-to-date policies and processes that align with other key partners involved in patient care. This meant that staff provided safe, high quality and consistent care and treatment to women and babies that was based on the latest evidence, research and guidelines.

We scored the service as 2. The evidence showed some shortfalls. Staff did not prevent the risk of baby abduction within the service. Staff did not always complete training on how to recognise and report abuse or follow up to date trust guidance. However, the service worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that.

The trust did not have effective systems in place to ensure staff identified, assessed and managed baby abduction risk in line with the trust policy. The ward was equipped with an intercom system at the main entrance, allowing staff to control entry and exit, during our assessment. However, we observed that staff did not routinely challenge individuals requesting access, which posed a potential risk of abduction.

During the assessment, we observed that the main entrance door to the maternity building did not close properly on both days, posing a risk of unauthorised entry or exit. We also observed tailgating at the main maternity entrance and postnatal wards. We observed that a new member of staff was left in charge of the reception areas, when they had not completed all necessary training and had not been given guidelines or standard operating procedures on baby abduction. We observed staff granting visitors entry without challenge.

Staff did not follow the baby abduction policy or undertake regular baby abduction drills. Staff told us there had not been a recent baby abduction drill in the last 12 months. Evidence provided by the trust showed there had been no recent baby abduction drill carried out in 2025. This meant there was a lack of preparation for what to do in the event of a baby abduction, and it was exposing women and babies to the risk of harm. We escalated our concerns to the trust, who advised post assessment that a reminder had been sent to staff and a baby abduction drill had been completed in October and December 2025. The service would continue to carry out a bi-monthly drill to sustain staff awareness and embed response and actions. The trust provided us with evidence that baby abduction drills had been carried out on the labour ward in October and December 2025. The reports from both simulation drills showed that on both occasions the babies were abducted without a challenge from staff and highlighted some areas for improvement, such as signing in and out of visitors. The findings from both simulations were similar to our findings during our assessment and highlighted the ongoing security risk. The service had developed an action plan to address the areas of improvement from both baby abduction drills.

Staff did not always complete training specific for their role on how to recognise and report abuse. The service provided medical and midwifery staff with level 2 and 3 safeguarding training for children and adults. As of 1 October 2025, midwifery staff achieved 79% compliance whilst medical staff achieved 47% compliance in the safeguarding children level 2 and 3 training. The medical staff achieved 59% compliance whilst the midwifery staff achieved 90% compliance in the safeguarding adult level 2 and 3 training. Service leaders told us and data showed that from 1 October 2025, the safeguarding training would be revised to make it easier to complete and more relevant to practice, and delivered in bite-sized modules, further improving staff compliance.

The service had a named safeguarding midwife for maternity, who played a key role in overseeing safeguarding cases, supporting staff and facilitating training sessions. During out of hours, any safeguarding concerns were supported by the on-call midwifery manager and the trust's site and on-call team.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff knew how to make a safeguarding referral and who to inform if they had concerns.

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

The service did not have an effective system in place to ensure that risks were identified and managed effectively. Staff did not maintain accurate and complete records of risk assessments and care provided to women and babies. Leaders lacked clear oversight of significant gaps in service users’ records, particularly in relation to modified early obstetric warning score (MEOWS), sepsis, pain audits and newborn assessments.

Where audits identified issues related to documentation and risk assessments, leaders did not take timely, effective action to address them. This increased the risk of avoidable harm as staff did not always have a full and accurate picture of the care provided to base their treatment and decisions upon.

Staff did not always use a nationally recognised tool to identify women at risk of deterioration. There were gaps in the entries and completion of MEOWS assessments and action plans. We reviewed the June to September 2025 MEOWS audit in recovery, which demonstrated an overall poor compliance rate of 54% against a target of 90% across the 6 standards audited. There was poor compliance with follow-up and extended observation of women carried out up to the first 2 hours and 4 hours, which was attributed to delay in transfers, handover issues, and documentation. The audit highlighted poor adherence to extended observation protocols. However, staff achieved 100% compliance on escalation of abnormal MEOWS. This demonstrated that staff identified and escalated concerns to doctors and senior leaders promptly in line with the trust policy.

We reviewed 12 sets of patient records whilst on site and found care and assessments were not always documented. Records were completed to varying standards, particularly in relation to the documentation of the named midwife, signature and dates, risk assessments, fluid balance charts and vaginal examination. We found over 30 reported incidents on LFPSE from 1 September 2024 to 16 September 2025 associated with poor documentation, risk assessment, lack of handovers and delay in admission/transfers or discharge. The gaps in staff documentation and risk assessment increase the risk of avoidable harm as staff did not always have a full and accurate picture of the care provided to base their treatment and decisions upon.

Staff did not always complete newborn risk assessments when babies were born, using recognised tools, and did not review them regularly. The Q2025-2026 audit of newborn assessment showed 81% compliance with the 5 standards audited; however, compliance was low in the hip pathway, which demonstrated significant delays in referrals, diagnostic testing, and decision-making, increasing the risk of harm to babies. The proportion of babies with a screen-positive newborn hip result who attended an ultrasound scan of the hips within the designated timescale was 57.1%, against a target of 90%. Of these cases, only 17% could have had their scan within the required timescale; however, no clear mitigating reasons were recorded to explain why this did not occur. The audit also identified that in 33% of cases, there were mitigations as to why the timescale could not be achieved due to factors outside the trust’s control. These included women declining the scan, arriving late for their appointment, or requiring rebooking. The proportion of babies with a screen-positive newborn hip result at newborn physical examination for whom an outcome decision was made within the designated timescale was 49.3%, against a target of 90%. This meant not all babies received a timely intervention and increased the risk of harm.

Staff did not always complete fetal monitoring risk assessments in line with national guidance and trust policy; delays could put women and babies at risk, as deteriorations in fatal conditions may not be identified in a timely way. From April to September 2025, the fetal monitoring audits demonstrated that hourly fresh eyes review compliance was 59.5%, below the 90% trust target, with low compliance primarily occurring during periods of high acuity. The result highlighted that improvement was also needed in the assessment and classification of cardiotocograph (CTG) in accordance with physiology and trust’s guidelines. Improvement was also needed in the hourly CTG risk assessment and documentation, and in the rationale for CTG not being completed. However, we noted a 27% improvement in compliance in the July to September 2025 audits on hourly fresh eyes compared to the previous quarter. An action plan was in place which had timescales and was monitored to improve compliance, including additional staff training and a weekly review of CTG cases.

The 2024 postoperative caesarean section pain audit showed poor compliance. The result showed that 42% of records had no documentation of pain scores of pregnant women. This can have a significant negative impact, leading to inadequate pain management, low satisfaction with care, and adverse physical and psychological outcomes for women. The service had not conducted a follow-up audit to provide assurance of improved compliance and patient outcomes. It was unclear how often senior staff were meant to carry out this audit.

The April to June 2025 sepsis audit results showed an overall compliance rate of 89%, with staff achieving 75% compliance in documenting senior reviews, initiating sepsis 6 within an hour of recognition, and checking lactate levels. This was against the trust target of 95%. Compliance with urine output measurement documentation was significantly low (63%). However, staff achieved 100% on some of the sepsis 6 bundle elements audited; such as blood culture, IV antibiotics and escalation to doctors. Staff achieved 88% compliance on escalation to the critical care team. It was unclear from the audit results whether performance had improved or declined compared to previous audits.

The April to June 2025 intrapartum documentation audit showed an overall compliance rate of 98% across 9 standards audited.

Staff completed the World Health Organisation (WHO) 5 steps to safer surgery checklist prior to starting surgical procedures. From April 2024 to June 2025, staff achieved 98% compliance. An action plan was in place, with action completed in line with the time planned to address gaps in the time-out standard.

Staff provided timely emotional support, guidance and assistance to women and those close to them. Individuals with mental health conditions or learning disabilities received tailored care to meet their specific needs, supported by a dedicated mental health midwife and access to mental health liaison services. Staff supported women to make informed decisions about their care.

Staff used the situation background assessment and recommendation (SBAR) model in the initial intrapartum risk assessments and to update their colleagues and handover care throughout the unit and recorded this on the electronic patient records. Staff achieved 97% compliance against the 95% trust target in the July 2025 audit.

Shift changes and handovers included all necessary key information to keep women and babies safe.

We scored the service as 1. The evidence showed significant shortfalls. 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 unit was open 24-hours a day, 7 days a week and maternity services included an antenatal clinic, triage, day assessment unit, labour ward and birth centre and a maternity ward.

The theatres, recovery, close observation unit, triage, and antenatal ward were close to the labour ward, allowing timely transfer when required. The maternity units required any visitors to be let in and out to maintain security however we observed tailgating during the assessment.

The trust did not have effective systems in place to ensure that the maintenance and use of facilities, premises, and equipment always adhered to safety standards. Systems to ensure equipment, including emergency equipment, was checked regularly, available and safe for use were not always effective. Daily checks were not completed for equipment, including emergency equipment, across the maternity unit. For example, on the labour ward, inspectors found 10 gaps in checks of the adult resuscitation trolley in July and September 2025. We observed 43 gaps in the resuscitaire equipment checks in a labour ward room from July to September 2025. We found a missing laryngoscope handle in the emergency trolley. Inspectors also found a size 0 Guedel airway in a drawer, which was not included on the emergency trolley checklist. We also observed 13 gaps in the recovery unit and 12 gaps in the antenatal ward in the same period of adult emergency equipment checks. This meant that emergency equipment may not be available in a timely manner when required.

The April to September 2025 emergency equipment check audit for the labour ward, showed poor compliance with the daily checks. Staff achieved an overall compliance rate of 65% on both day and night shifts. The result showed a decline in performance from April to September. For example, staff achieved 87% compliance during the day shift in April compared to 57% in September. Night compliance dropped from 63% in April to 53% in September 2025. The service achieved 80% compliance in the neonatal resuscitaire equipment check audit. We were concerned that leaders had failed to take action to address the issue and improve staff compliance with daily checks of equipment.

Some equipment safety checks were outdated and not fit for purpose. We observed several items of equipment, such as cardiotocography (CTG) and blood pressure machines, that had not been serviced or portable appliance tested (PAT) annually. For example, the CTG and blood pressure machines had been overdue for servicing or PAT testing since June 2025 and February 2025, respectively. This can lead to faulty or equipment failure, fire hazards and inaccurate diagnostic data therefore increasing the risk of harm to women and babies.

The maternity service lacked sufficient equipment. During the assessment, staff told us and we also found a shortage of and damage to equipment such as a cold cot, CTG, and blood pressure machines. Inspectors found that triage did not have a grab bag to use during an emergency, which increased the risk of potential harm to women and babies. Following the assessment, the trust told us there was a delivery pack available in triage that was used during unexpected rapid deliveries. The triage emergency call bell was linked directly to the labour ward and alerted staff to attend immediately in the event of an emergency. The service’s emergency grab bag was located on the labour ward, which was less than 10 metres away and would be easily accessible to staff. However, the trust did not provide information to confirm whether the absence of an emergency grab bag in triage had been formally risk assessed or whether a simulation exercise had been undertaken to determine how quickly triage staff could access the grab bag on the labour ward.

Staff reported several incidents relating to faulty and unavailability of equipment. A review of LFPSE data from 1 September 2024 to 16 September 2025 showed that staff reported 10 incidents relating to the faulty or unavailability of equipment such as, CTG, hot cots, observation machines, resuscitaire, and ventilators. The service also reported 8 incidents related to faulty lifts and 3 incidents around estate and premises. Staff told us that actions were not consistently taken in a timely manner to address these faults. We raised our concerns to the trust post assessment and no evidence was provided on timely actions taken to address these faults.

Expressed breast milk was not kept in a secure environment in line with the trust policy and British Dietetic Association (BDA) guidelines for the Preparation and Handling of Expressed and Donor Breast Milk. Inspectors found that the milk fridge on the labour ward, including the door to the room where it was stored, was not locked, which was easily accessible to other women and their partners. This increased the risk of contamination, theft and access to sterilised facilities.

From July to August 2025, the staff achieved 97% compliance in the environmental mattress and sluice audits.

Staff disposed of clinical waste safely.

We observed and women told us they could reach call bells and staff responded quickly when called.

A recent ligature risk assessment was conducted across the unit to identify and evaluate attachment points for self-harm to minimise the risk of harm to women. There was an action plan in place to mitigate risk found on the risk assessments.

Birthing partners were welcomed and supported to attend births and provide care and reassurance women across all areas of the service. The service had suitable facilities to meet the needs of women's families. In the event of a fetal loss, the service offered bereavement facilities to support families. At the time of assessment, the bereavement suite was being refurbished and was out of use for 1 to 2 months. The service planned to relaunch the new bereavement suite and garden suite, funded by a charity, during Baby Loss Week in November 2025. Staff told us they would use a room in the delivery suite if they needed to care for a bereaved family whilst the bereavement suite was being refurbished.

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. They did not always work together well to provide safe care that met people’s individual needs.

The number of midwives and care assistants did not always match the planned numbers in all maternity areas. However, this had improved significantly over time through recruitment initiatives led by senior leaders. From September to August 2025, the fill rate was above 90% against the trust 90% target. Leaders told us that work had been done to reduce the shifts filled by agency staff from 74.3% to 21.7%. The bank staff fill rate ranged between 59% to 80% and agency was 18% to 31%. The unfilled shift rate ranged approximately between 5% to 7%. The majority of the unfilled shifts related to specialist midwives, the continuity of care team, transitional care, the antenatal clinic, the birth centre, and the community midwifery team. Safe staffing was achieved through the use of temporary staff and redeployment of staff from low acuity to high acuity areas. When necessary, managers deployed agency and bank maternity staff familiar with the service to maintain safe staffing levels. Managers provided new staff with an appropriate induction.

Hospital data showed that there had been one night shift during Q3 24/25 where the unit was put on divert due to acuity and staffing within the unit. The escalation protocol was initiated, and the on-call midwifery manager attended the unit to ensure safe care was delivered. The diversion ceased the following morning and service was back to normal.

There was a supernumerary shift co-ordinator on duty on every shift, who had oversight of the staffing, acuity, and capacity. Managers accurately calculated and reviewed the number of midwifery staff needed for each shift, in accordance with national guidance using an acuity tool.

The service completed a maternity safe staffing workforce review in line with national guidance in October 2023. This review recommended 153.52 whole-time equivalent (WTE) midwifery staff Band 3 to 7 compared to the funded staffing of 148.61WTE, a negative variance of 4.91WTE staff. At the time of our assessment, the midwives and specialist midwifery workforce had increased since the birthrate plus was completed, in response to Ockenden's recommendations. The service was due for its next staffing workforce review in 2026.

The service monitored maternity staffing incidents classified as ‘red flags’ in line with the NICE guideline: Safe Midwifery Staffing for Maternity Settings. A midwifery ‘red flag’ indicates a potential issue with staffing levels. Between October 2024 and March 2025, the service recorded 10 red flag events relating to staffing. The most frequent red flag events included the delays between admission for induction and beginning of process and delayed or cancelled time critical activity. Actions were taken by senior leaders following red flags events to ensure safe staffing and safety of women and babies.

The service had reduced vacancy rates for midwifery staff. Vacancy rates had reduced from 30% in April 2023 to 12.4% in August 2025, and at the time of the assessment, the vacancy rate had reached 0%. Leaders told us this was due to the introduction of initiatives such as apprenticeship pathways and proactive recruitment, and retention drives for staff. The service had also recruited 2 of their qualifying student midwives on the apprenticeship pathway who were qualifying at the end of December 2025. However, the service's current challenge was skill mix as most midwives recently recruited were newly qualified and internationally trained midwives who required continued support. Staff told us this placed an additional burden on experienced midwives and labour ward coordinators. The service had low sickness rates. Data from Q3 and Q4 2024/2025 showed an average sickness rate of 2% among midwifery staff.

Midwives and maternity assistants were supported by a dedicated practice development team which included clinical placement facilitators, practice development midwives, a preceptorship lead midwife, a fetal wellbeing midwife and professional midwifery advocates. The service also had specialist midwives such as the diabetic midwife, bereavement midwife, infant feeding lead and preceptorship health care assistant lead midwife. The specialist midwives supported staff and ensured mothers and babies received safe, effective and compassionate care.

The service had a maternity screening team which included 2 screening lead midwives, a band 6 midwife and band 3 screening support worker. There was a vacancy for a screening support worker, who was currently going through approval to convert this to a band 4 failsafe officer. This was in response to a recommendation from an external screening quality assurance service visit.

The service did not always have sufficient medical staff in all maternity areas to ensure the safety of women and babies. At the time of our assessment, the service employed 22 substantive medical staff, 1 substantive associate specialist, 11 registrars, 10 resident doctors. The obstetric team responsible for the labour ward also covered triage in and out of hours, which was insufficient and did not align with national guidance, leading to delays in women's reviews. The obstetric team also covered other maternity areas which sometimes led to delay in the review of women and prescribing medicines if they were busy on the labour ward or theatre. However, senior staff told us and we observed that during the daytime, an extra registrar covered the DAU and antenatal ward during times of high acuity. The service always had a consultant on call during evenings and weekends. At the time of our assessment, the service had 2 vacancies for registrars and these posts were covered by locums.

Managers could access locums when they needed additional medical staff. Managers ensured that locums had a comprehensive induction to the service before they began work.

The service had a good skill mix of medical staff on each shift, which was reviewed regularly. The anaesthetic rota complied with Anaesthesia Clinical Services Accreditation standard 1.7.2.1, and the maternity service had a dedicated anaesthetist available 24 hours a day, 7 days a week to cover the labour ward for elective and emergency caesarean sections.

Not all staff are up to date with their mandatory and maternity-specific training modules. Staff did not always receive adequate training, skills, and drills, as well as regular appraisals, to carry out their roles and responsibilities safely. The completion rate was significantly below the trust target for staff appraisal and some training modules, particularly obstetric emergencies, baby abduction drills, safeguarding, suturing, risk management, pregnancy loss, basic life support, student supervision, and assessment. The service had action plans in place to improve mandatory training and appraisal.

The trust data showed an overall compliance rate of 84.7% for Practical Obstetric Multi Professional Training (PROMPT) against the trust target of 90%. The midwives, theatre nurses, specialist registrars and resident doctors met the trust target. Compliance rates were 85% for the maternity assistants and 89% for the anaesthetic consultants. However, the obstetric consultant achieved 69% and the anaesthetic specialist registrars and resident doctors achieved 75% compliance. Post assessment, the trust advised that as of 19 December 2025, 94% of obstetric consultants and 95% of anaesthetic resident doctors had completed their training. We have not reviewed the impact of the changes.

In the same period, 86% of midwifery and medical staff had completed the cardiotocograph (CTG) training against the 90% trust target. Staff also achieved 91% compliance in the newborn life support training.

Staff were also required to complete some maternity-specific training modules, such as screening and pregnancy loss, on an annual basis. Data showed overall poor compliance of 78.3%. Data for midwives suturing training also showed poor compliance of 69% against a trust target of 90%. The trust did not provide us with evidence of actions to be taken to improve compliance.

Data showed that 76% of midwives had completed the Standards for Student Supervision and Assessment (SSSA) training and 79% of midwives had completed their risk management and pregnancy loss training against a trust target of 90%. Data showed that 80% of midwives had completed their basic life support training against a trust target of 90%. Post assessment, the trust advised that as of 19 December 2025, 93% of staff had completed the training. However, the trust did not provide us with evidence of the improved training data, and we have not reviewed the impact of the changes.

The trust did not have effective systems in place to ensure both midwifery and medical staff were competent to provide safe and evidence-based care for women. Managers did not always appraise staff’s work performance, make sure staff were competent for their roles or hold supervision meetings with them to provide support and development. As of 1 October 2025, 71.2% of midwifery staff and 77% of medical staff had completed their appraisal, which did not meet the trust target of 95%. The trust had identified that the reason for low compliance was due to incomplete performance and development reviews during the appraisal window (April to June 2025) and lack of follow-up and real time oversight and accountability from leads. However, this demonstrated a lack of support and robust monitoring and oversight from leaders to identify, escalate, and address the performance issue in a timely manner. The service advised they had actions in place to monitor and drive improvement.

Staff completed regular skills and drills sessions, except for the baby abduction drill. The 2025 skills and drills live simulation log showed that staff had completed several drills such as postpartum haemorrhage, neonatal resuscitation, shoulder dystocia, maternal collapse, sepsis and pool evacuation.

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.

The maternity departments looked visibly clean and free of clutter. All ward areas were clean, had required furnishings and were well-maintained. We inspected all areas of the maternity unit, including labour ward, obstetric theatres, wards, triage and the antenatal clinic. Cleaning schedule checklists were up to date and clearly displayed. Recent overall cleaning scores for the units were up to date and displayed, showing compliance. However, the data showed poor compliance with the cleaning audit, with staff achieving only 71%. There was no evidence of action taken to improve compliance.

Staff did not always adhere to infection control principles, including handwashing and use of personal protective equipment (PPE). We observed staff following IPC guidelines in most areas, they were bare below the elbows and followed hand hygiene between patients. Hand hygiene audit results were up to date and displayed in the unit, showing good compliance. From July to September 2025, staff achieved 94.6% overall compliance in the hand hygiene audit. However, at the time of assessment on labour ward, staff were observed to not always be bare below the elbow. This had been addressed in the environmental cleanliness and infection control audit in May 2025 with reference to trust uniform policy. In theatres, there was non-compliance with mattress audits, which had been addressed in the environmental cleanliness and infection control audit in July 2025.

The service reported one case of Methicillin-resistant Staphylococcus aureus (MRSA) between the month of July and August 2025. It was unclear if this was above or below the trust target.

The service did not meet the control of substances hazardous to health (COSHH) standards. We observed cleaning detergent being stored in areas that were not secure and where unauthorised individuals may have access. This issue was escalated to leadership and rectified immediately.

Staff maintained the equipment; it was noted to be free of dust and kept clean. Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned.

Staff had clear roles and responsibilities around infection prevention and control. The maternity department had a designated IPC lead, whose identity was displayed on the notice boards on the unit. The department also had a housekeeper who was highlighted as an invaluable member of the team, to keep the consistency of good standards especially around mattress care and audits.

The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. However, they have involved people in planning.

The service did not always manage and administer medicines safely. While some aspects of medicines management met expected standards, there were significant areas that needed improvement to ensure patient safety and compliance with best practice.

Fridge temperatures in clinical areas were not always monitored regularly. Daily checks of ambient room and fridge temperatures were not always completed as required across the maternity units, particularly on the labour ward and postnatal wards. There was low compliance for fridge and freezers where medicines were stored and ambient room temperature in the last 3 months. This posed a significant risk to women's and babies' safety as medicines not stored at the right temperature can lose their effectiveness and potency.

Women told us they experienced delays of up to 4 hours in receiving their induction of labour medications. The women said these delays were often due to a lack of doctors available to prescribe medicines promptly. Staff told us that these delays occurred when the doctors were busy in the theatre, labour wards or ward rounds. Such delays can affect treatment effectiveness and reduce patient confidence in the service.

Medicines were mostly stored in line with best practice, and staff had access to suitable spaces for preparation. Emergency medicines were available and checked daily in theatres to ensure they were safe for use. The service used a electronic prescribing and medicines administration (EPMA) system, which helped reduce risks and ensured any medicine omissions were documented correctly.

The trust had introduced measures to improve controlled drug management in response to learning from incidents. This included staff training, ad-hoc study days, medicines management assessments for preceptors, and practical drug rounds to reduce risks.

Overall, while some good practices were in place, significant issues remain in medicines management, monitoring, and timely prescribing, which could compromise patient safety.