St George's Hospital (Tooting)

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 inspection we rated this key question as inadequate. At this inspection the rating has remained inadequate. This meant that people were not safe and were at risk of avoidable harm.

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse, and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation. 

The service was in breach of the legal regulations relating to safe care and treatment. We saw high levels of staff shortages and lack of oversight in maternity triage. We also raised concerns regarding the storage of medicines and found out of date medicines in the drug cupboard in triage and delivery suite adult resuscitation trolley. Following our inspection, we issued a warning notice to the trust asking for significant improvements to be made. The trust then made some improvements to the service to help keep women, birthing people, and babies safe.

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.

Managers did not always investigate and manage complaints and safety incidents well. The service did not always ensure that actions and learning from safety incidents were implemented in a timely manner and monitored to drive improvement. However, staff recognised and reported incidents and near misses.

The service had systems and processes in place for the reporting and investigation of incidents and complaints. However, investigations were not always completed in a timely way impacting the services ability to learn from incidents and make required changes to keep women, birthing people, and babies safe. We reviewed minutes from an internal meeting in September 2024 and found 144 incidents were overdue. In addition, the trusts complaints policy mandated a 25-day and 40-day turnover. However, in July and August 2024 only 50% of complaints were responded to within 35 days, which was below the target of 85%. Whilst they met a 55-day response time for complaints, this was not in line with the stated timeframes in the complaints policy. This could put women, birthing people, and babies at risk. This concern was also raised at the last inspection.

A Maternity Safety Support Programme (MSSP) report from 2023 identified that some staff felt there was a blame culture within the maternity service at that time. However, the trust informed us following the inspection, that work had been undertaken to improve the culture across the unit. During the CQC inspection, the multidisciplinary staff we spoke with reported they were encouraged and supported to raise concerns and reported an improved culture around reporting incidents.

Staff recognised and reported incidents appropriately and knew how to raise concerns using the hospital’s electronic incident reporting system in line with the hospital’s incident reporting policy. Managers were responsible for investigating incidents and sharing the learning. Learning from incidents was shared through various means, for example handovers, 5 facts shared learning emails, staff meetings, and posters. There was evidence that changes had been made and embedded because of learning identified from previous incidents and was widely disseminated. Staff we spoke with were able to give examples of how the service had improved following incidents. This was an improvement from the last inspection.

Most staff we spoke with were able to explain the duty of candour. They were open and transparent and gave women, birthing people and their families a full explanation if and when things went wrong. In all 3 incident investigations reviewed, managers shared duty of candour and draft reports with the families for comment. An audit completed in August 2024 which assessed service user engagement in the perinatal mortality review process, found that 18 (78%) people were given written duty of candour and 5 (22%) were given verbal duty of candour. After the inspection, the trust told us that in line with trust policy 100% of the women were informed that a suspected or actual patient safety incident had occurred within 10 working days of the incident being reported. The discussion was accompanied by the offer of a written notification which was taken up by 18 people. 5 people were satisfied with the verbal discussion and did not want written notification. However, a written notification should be provided as stated in Health and Social Care Act (2008) Regulation 20 (Duty of Candour). Further improvements could be made to ensure all staff understand the importance of duty of candour and are able to act appropriately.

Staff and leaders we spoke with told us that there had been an improvement in the categorisation of incidents since our last inspection. However, during the inspection, we identified issues with the categorisation of post-partum haemorrhage (PPH) and third-degree tears incidents. Following the inspection, the trust evidenced that managers and governance teams corrected all PPH and tear incident grading errors to ensure all incidents were graded appropriately. Following the inspection, the trust informed us about a national software limitation issue related to the Learning from Patient Safety Events (LFPSE) system which prevented trusts from amending data once submitted. At the time of writing this report, this national issue remained unresolved, however incidents were graded appropriately within the trust held data.

All cases of PPH over 1.5 litres and third- and fourth-degree tears were discussed at daily incident review meetings led by the divisional governance team and escalated directly to the obstetric risk lead.

In November 2023, the Maternity Improvement Advisor Group's diagnostic report revealed a relatively low number of reported moderate harm incidents. This raised concerns about potential incorrect incident grading. In January 2024, an external team of midwives and doctors conducted a perinatal mortality report based on deaths within the service in 2020. Their review found that 23.6% of cases, initially graded "A" (meaning "would not have had an impact on the outcome"), were incorrectly categorised. The external team subsequently changed these gradings to "B". This demonstrated the need for further improvements in incident categorisation and grading to ensure all learning opportunities are fully explored.

By October 2024, midwives had achieved 85% mandatory training completion, while doctors had reached 78%, falling below the 85% trust target. This raised concerns about staff knowledge and service user safety. However, PREVENT Level 3 training compliance was 93.6% for midwives and 88% for doctors. In August 2024, 86% of midwives completed cardiotocography (CTG) training, and a plan was put in place to reach the 90% target by November 2024. Post-inspection, the trust reported improved mandatory training compliance. Since the inspection, the trust had reviewed and updated its governance framework for the oversight of mandatory training compliance and an action plan had been put in place for staff to achieve 90% compliance by the end of March 2025.

Incidents were appropriately referred to the Maternity and Newborn Safety Investigations (MNSI) team and findings were discussed by the senior leadership team.

Women and birthing people we spoke with felt safe, reported risks were not ignored and knew how to raise a complaint.

Staff did not assess, manage, or monitor risks to the safety of women, birthing people, and babies. Documentation was not completed fully.

Staff told us they were trained to respond to risk and were able to identify and act when women and birthing people were at risk of deterioration. However, staff did not always complete risk assessments or take action to remove or minimise risks, and documentation was not always completed appropriately.

The Maternity Early Obstetric Warning Score (MEOWS) audit, completed in October 2024, identified significant gaps in patient records as “additional concerns” were correctly documented in 55% of women and birthing people notes. This was significantly below the trust target of 80%. This meant a full risk assessment was missing in a high proportion of notes and could mean that there were delays identifying deteriorating women or birthing people. Similar results had been identified in previous audits and appropriate action had not been taken and there had been incidents which have been associated with poor documentation and risk assessment. Following our inspection, the trust provided us with the results from an audit completed in February 2025 examining the use of MEOWS on the maternity wards. This audit showed increased compliance, with “additional concerns” being documented in 85% of notes examined. This was an improvement and met the trust target of 80%. However, the MEOWS was still not fully completed as postnatal pulse rate was recorded in 74% of the notes examined. This highlighted that further work was needed to ensure risk assessments are fully completed to ensure women and birthing people are safe. The trust had reported that a revised governance framework for monitoring of audits and areas of poor performance had been put in place.

Although there had been improvements in triage since our last inspection, systems and processes were not fully embedded to ensure women and birthing people were safe. A trust audit completed in September 2024 found that the time doctor consultations took place was recorded in 49.8% of patient notes. Following the inspection, the trust submitted results from a retrospective audit completed in July 2025 reviewing data from September 2024. This audit reported the time doctor assessments took place was recorded in 92% of patient notes. However, the sample size of this audit was significantly smaller (25 compared to 647 in the original audit).

There were also gaps in the daily checks of triage results completed by staff. This meant that women and birthing people were put at risk of harm as results of investigations were not being followed up appropriately in line with trust policy. In response to the warning notice, the trust added an electronic whiteboard to track medical reviews and changed triage procedures to ensure all test results were acted upon. A new operating procedure had been implemented outlining roles and responsibilities to ensure the daily checks were completed and all investigation results were acted upon. A follow-up audit in December 2024 and January 2025 showed that compliance was below the trust target of 80% (70% and 74% respectively). Therefore, further work was needed to ensure daily checks are completed so that women and birthing people are safe.

Staff did not effectively assess, document, or respond to ongoing risks to the safety of women, birthing people, and babies at all stages of pregnancy in line with national guidance. Staff did not always use a triage system to prioritise women and birthing people when they arrived in triage, and we observed gaps in the documentation of the “red, amber, green” (RAG) rating in the patient records. This was an on-going concern which was raised at the previous inspection. There were gaps in the completion of the risks assessments in patient records, for example during telephone triage conversations, and there were also gaps in the documentation within triage. We found inconsistency in the telephone triage assessment and documentation used during working hours and out of hours. The telephone triage line did not have dedicated cover 24 hours per day, 7 days a week. The triage telephone line was diverted to the labour ward and manned by the labour ward coordinator during staff breaks during the day and out of hours from 8pm to 8am. This was not in line with guidance from the Royal College of Obstetricians and Gynaecologists (RCOG). Following the inspection, the trust was issued a warning notice and asked to make significant improvements to the maternity service, including the triage service. The trust changed its practice, and a 24-hour maternity triage telephone line was put in place to ensure women and birthing people can get help and advice when they need it, and calls are no longer diverted. A new electronic notes system was also introduced after the inspection with mandatory fields to ensure full assessments are completed during working hours and out of hours.

Staff told us there was only 1 resident doctor who covered all the maternity units, gynaecology and emergency gynaecology cases in the emergency department at night. After the inspection, the trust informed us there were 2 resident-grade doctors present on site overnight, supported by a consultant available on call from home. The hospital did not have a dedicated gynaecology ward, and the emergency department was not located within close proximity of the maternity units, which contributed to the delay in care by medical staff at night and out of hours. Therefore, the service was unable to provide assurance that women and birthing people received a timely medical review at night.

Despite staff receiving training in CTG interpretation, we found there was inconsistency in the categorisation of CTG and staff used different terminology in documentation when classifying and interpreting CTG traces which was not in line with their policy. This was seen by inspectors and our Specialist Advisors during the inspection when they reviewed patient documentation. Variation in terminology could lead to confusion when CTGs were discussed or when concerns were escalated. Since the inspection, the trust introduced a new electronic documentation system which mandated set terminology from drop down boxes to ensure consistent terminology in line with policy.

NHS Resolutions conducted a thematic review of all cases referred to MNSI by the service between April 2017 and May 2024 and the findings were reported in the January 2025 board papers. The review identified that there should be greater assurance around the documentation of intrapartum CTG traces to ensure that women, birthing people, and babies were kept safe.

The trust’s policy mandated hourly CTG review and two hourly “fresh eyes”, deviating from the 2022 National Institute for Health and Care Excellence (NICE) guideline of hourly “fresh eyes”. This deviation had been risk assessed by the trust. However, a November 2024 external investigation report found staff were over reliant on the electronic CTG central monitoring system, issues around escalation of concerns and staff assumptions around abnormal CTG traces. Post-inspection, the trust aligned its CTG monitoring with the NICE hourly “fresh eyes” recommendation.

The service had specialist midwives to support vulnerable women and consultant obstetricians were present for difficult births. Staff reported it was easy to escalate concerns. Staff were confident to escalate concerns, and reported it was easy to do so, and staff felt they were adequately trained to respond to risk.

Staff and senior leaders collaborated with external teams appropriately for example the Maternity and Neonatal Voices Partnership (MNVP) and the Maternity Safety Support Programme. Staff and senior leaders engaged with these external agencies around their systems and pathways and took their views into account. Following the inspection, we reviewed the MNVP action plan for 2024 – 2025. Several projects were included through collaboration between the trust and MNVP and a lead for the trust and the MNVP was included for each project area.

The service had improved their documentation around bereavement since the last inspection.

Staff followed up-to-date policies and processes that align with other key partners involved in patient care. The service had systems, processes, and policies in place to assess and respond to deteriorating patients, sepsis, and PPH. Staff had received appropriate training on sepsis and perinatal mental health.

The service did not have effective systems in place to ensure staff received adequate safeguarding training to carry out their roles and responsibilities safely. There were ineffective systems in place to reduce the risk of baby abduction.

Relevant safeguarding training was available; however not all staff had completed this. In October 2024, 69% of midwives had completed Level 2 safeguarding children training, below the trust’s 85% target. Medical staff compliance was also below target: 73% for Level 2 safeguarding children and 82% for Level 2 safeguarding adults. We escalated this to senior leadership and following the inspection, the trust provided data to show that mandatory training compliance rates had improved. As of January 2025, 85.8% of midwives and 78.7% of doctors had completed the Level 2 safeguarding children training and there was an action plan in place to achieve 90% compliance by the end of March 2025.

Senior staff told us the baby abduction policy was embedded in the maternity safeguarding policy. However, staff we spoke with were either not aware of this or had difficulty locating the policy on the trust intranet. Therefore, we were not assured staff had a good understanding of the protocols in place to prevent baby abduction.The maternity wards had some security controls such as CCTV, swipe card, and buzzer access. However, on the postnatal ward there was a fire exit opposite the staff desk which could be easily accessed to exit the ward without staff oversight. This increased the risk of baby abduction. This was raised with the trust at the time of the inspection, and we were told that an alarm would sound if the exit was used which would alert staff to the situation. However, during the inspection we found the fire exit door open on 2 occasions, and we escalated this to senior staff. At this time, no alarm was heard, and staff were unaware the door was not securely closed. Following the inspection, the trust informed us that the door was fitted with a self-closing device which was found to be faulty at the time of the inspection. This prevented the door from fully closing when it had been opened using the swipe card access point. The fault was escalated by the trust and was then repaired.

The risk of baby abduction was further increased as there was no baby tagging system in place on the postnatal ward. Inspectors also received concerns from staff regarding the lack of swipe card controlled access between the delivery suite and maternity theatres which meant that surgical staff could access maternity areas, contradicting Health Building Note 09-02 guidelines. These guidelines mandate restricted access to maternity areas because less restricted access increases the risk of baby abduction.

The service had implemented a maternity safeguarding policy since the last inspection. Staff were able to explain how they identified adults and children at risk of, or suffering from, significant harm and how to report safeguarding concerns. There was a safeguarding lead midwife within maternity who provided additional support and guidance as required. There were systems in place to investigate, discuss, and share learning from any safeguarding incidents, as well as a system to flag any safeguarding concerns on the electronic patient records. We observed safeguarding concerns being appropriately discussed during handovers and documented within electronic patient records.

Women and birthing people we spoke with felt safe and well supported by staff.

The service did not always work well with women and birthing people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them. Significant issues persisted with risk assessments, particularly for women and birthing people attending triage.

Local Safety Standards for Invasive Procedures (LocSSIPs) were developed in line with NHS England and World Health Organisation (WHO) Safer Surgery Checklist. Trust data from May and October 2024, showed non-compliance with LocSSIPs putting women, birthing people, and babies at risk of harm. There was a large amount of incomplete data and one of the action points identified by the service was to liaise with team leaders regarding the lack of audits completed.

During our inspection, we found that staff did not follow the telephone triage line processes to ensure thorough assessments were completed. There was no standardised assessment or documentation during and outside working hours. Inconsistent assessment and documentation meant delayed care escalation, risking harm to women, birthing people, and babies. Post-inspection, the trust implemented a standardised electronic notes system for maternity triage assessments and introduced electronic audit reporting for compliance monitoring.

Staff told us that midwifery staff working in areas other than triage were expected to answer triage calls, especially during lunch and out of hours, without specific training or completion of required competencies. This raised concerns about their ability to manage triage calls, conduct risk assessments, and maintain records. This was particularly concerning during high-acuity periods on the delivery suite which could put women, birthing people, and babies at risk. Following the inspection, the trust reviewed the cover in maternity triage to ensure that there was dedicated midwifery cover within the telephone triage service 24 hours a day.

RCOG recommends that women and birthing people are triaged within 15 minutes of attending maternity triage. Data from the September 2024 triage audit showed that 95% of women presenting were seen within the trust 30 minute target and 79% of women were seen within 15 minutes. There were significant gaps in staff documentation which impacted in the accuracy of the waiting time data. The audit identified that 60.5% of women and birthing people had a medical review in line with targets. Medical review times were not always documented in records, and it was therefore unclear how long women and birthing people were waiting for a review by a doctor. Due to problems with the paper documentation used, the RAG rating assessments included in this audit were calculated retrospectively. Following the inspection, a new electronic notes system was introduced by the trust to support better record keeping.

The Newborn Early Warning Trigger and Track risk assessment tool was used by the service to highlight babies at risk of deterioration. An audit completed in July 2024 found that the total score was documented in 85.3% of cases and with “additional concerns” documented in 92% of cases against the trust target of 80%.

Staff felt they were adequately trained to respond to risk and had completed relevant training including Practical Obstetric Multi-Professional Training (PROMPT). Staff told us they knew how to assess, identify, and manage patient risks.

The service did not always detect and control potential risks in the care environment. Staff did not make sure equipment, and facilities supported the delivery of safe care. Facilities were not always well-maintained, and some areas presented risks that could impact patient safety. 

The maternity unit layout breached Health Building Note (HBN) 09-02 guidelines due to its multi-floor design. There was a risk assessment for transferring women and birthing people in labour from the birth centre to the delivery suite. Staff had priority passes for lifts to ensure transfers were managed in a time-appropriate way. However, lifts were situated in public corridors which did not maintain the privacy and dignity of women and birthing people being transferred. During our inspection we also observed that one lift was out of order which delayed the transfer and movement of women within the maternity units. This could also impact on availability of lifts and transfer of women or birthing people during an emergency. Staff told us the trust had completed some repairs and responded to feedback, but further improvements were needed. The maternity unit maintained a dedicated second operating theatre, ensuring immediate availability for emergency procedures.

The maternity service breached HBN 09-02 guidelines; birthing rooms lacked ensuite facilities, and postnatal women and birthing people had to walk some distance to access bathrooms. There were issues around flooding and sewage that mostly impacted the birth centre and antenatal ward areas. Leaders were aware of these issues, and it was recorded on their risk register. We observed the bathrooms on the postnatal ward were not always kept to a good standard and general wear and tear and mould was observed. This was escalated to senior leaders. A toilet on the postnatal ward was out of order at the time of our inspection. Staff told us that maintenance and repairs were not completed in a timely way. The trust told us improvements had been made, following the inspection, to treat the mould and strengthen the cleaning audit process. There was a plan in place to refurbish toilet and shower facilities on the postnatal ward by the end of March 2025.

During our inspection, we observed three beds being stored in the postnatal ward corridor which posed a safety risk. It is important that corridors are kept clear to ensure easy access and space to move women, birthing people, and babies in an emergency.

The service did not always have suitable facilities to meet the needs of women and birthing people. The service had birthing pool facilities in the birth centre and the labour ward, however, two of these were out of order. There were appropriate legionella water checks in place and staff said that pool evacuation drills had taken place. Data regarding pool evacuation drills was requested however this information was not received from the trust. In November 2024, an audit was completed looking at the documentation of birthing pool temperatures. There was an 83% compliance on hourly water temperature checks, but hourly maternal temperature checks were documented 72% of the time which was below the trust target of 80%. This showed that there were improvements to be made in the assessments completed during labour to ensure women, birthing people, and babies were safe.

We found out of date emergency medicines on the adult emergency trolley in the delivery suite. Daily checks were not always completed for equipment, including emergency equipment, in the birth centre and triage. For example, we reviewed the records from May to October 2024 and found 5 omissions in the daily checks of the PPH trolley, 12 omissions on the emergency neonatal trolley and 34 omissions in the daily checks of 2 resuscitaires in the Birth Centre.

We also found out of date medical consumable items in the clinical trolleys in triage and out of date medicines on the resuscitation trolley in the delivery suite. This could put women, birthing people, and babies at risk as emergency equipment may not be safe or ready to use during an emergency. Following the inspection, a warning notice was issued to the trust which asked them to make significant improvements. Post inspection, the trust told us they have reviewed the standard operating procedures and processes have been clarified and confirmed with staff and managers.

We observed 6 gaps in the daily check of equipment in triage from 5 to 10 October 2024 along with 5 gaps in the daily checks of the emergency PPH trolley in the delivery suite. We reviewed the resuscitation equipment audits for September 2024 which showed 69% compliance. This was not in line with the trust’s policy and could expose women, birthing people, and their babies to harm.

Staff were proud of the new bereavement suite which was designed in line with guidelines from the Stillbirth and Neonatal Death Society (SANDS) which is a charity that supports anyone affected by pregnancy loss or the death of a baby. This was an improvement since the last inspection.

There were policies and processes in place for deep cleaning and decontamination of equipment after use. Staff disposed of clinical waste safely; we observed sharps bins being filled within a safe limit and clinical waste and domestic waste being segregated and labelled correctly.

Women and birthing people we spoke with reported they were cared for in safe environments that met their needs. Staff reported there was enough suitable equipment to meet the needs of their patients and their families, for example CTG machines, resuscitation equipment, and fetal blood analyser, however they pointed out that equipment was sometimes faulty.

Women could reach call bells, and we observed staff responding quickly when called on the maternity wards.

The service did not make sure there were enough qualified, skilled, and experienced staff. While efforts were made to maintain safe staffing levels, such as redeploying staff and using bank and agency staff, this approach often resulted in gaps in coverage across some areas. Managers did not always make sure staff received effective support, supervision, and development. This was an ongoing concern from the previous inspection.

Staffing levels did not always match the planned numbers putting the safety of woman, birthing people, and babies at risk. There were a high number of unfilled shifts in the midwifery rota. The unfilled shift rates for registered nurses and midwives from June to August 2024 was 19.5% on the wards. This meant there was insufficient staffing cover which could impact on the ability of the ward to offer safe care and treatment to women, birthing people, and babies. Furthermore, an audit into the maternity high dependency unit (HDU) found that, during July to September 2024, 13% of night shifts did not meet local guidance of 1 HDU trained midwife and 1 HDU trained nurse.

Shortage of midwifery staff had been rated as an “extreme risk” on the trust’s risk register. Safe staffing was impacted by a number of factors including the high level of sickness across the service. Sickness rates of 4.04% and 5.05% were reported in May and June 2024 respectively. This was consistently higher than the trust target (3.2%) and had been included on the trust’s risk register. Data showed low staffing numbers had been raised as a concern by staff during the weekend of 24 and 25 August 2024, when annual leave and high sickness rates impacted on patient care. As a result, there were 10 delays in the induction of labour (IOL), no home birth team on Saturday 24 August 2024 and there was no midwifery manager on call. Appropriate mitigations and escalations were not always put in place which put women, birthing people, and babies at risk of harm.

There was an escalation policy and processes in place to attempt to mitigate staffing levels and the birth rate plus acuity tool was embedded into the service. Staffing levels were discussed at regular meetings to help senior leaders adjust staffing levels. However, the ward manager did not always have the resources to adjust staffing levels daily according to the needs of woman and birthing people. Managers moved staff according to the number of woman and birthing people in clinical areas but staff told us this was at short notice and sometimes meant they were expected to work in areas unfamiliar to them.

The service reported maternity ‘red flag’ staffing incidents in line with NICE guideline 4 - ‘Safe midwifery staffing for maternity settings’. A midwifery ‘red flag’ event is a warning sign that something may be wrong with midwifery staffing. Between January and September 2024 there were 62 red flag incidents reported. The most common incidents were delays of 2 hours or more between admission for an IOL and the start of the process (23) and delays or cancelled time-critical activity (16).

Following the inspection, staff raised concerns with us around the low staffing levels on the transitional care service. Staff identified occasions where unqualified support staff were expected to care for a high number of babies on their own during night shifts putting babies at risk. After the inspection, the service informed us that the transitional care service was a new service being set up. Staff recruitment was ongoing, aiming for operation 24 hours per day, 7 days a week by January 2025.

Staff reported that the maternity triage telephone line occasionally had to close due to sickness and records showed the telephone line was closed six times from August to October 2024. Women, pregnant people, and babies were at risk of delays in accessing advice and support due to the closure of this service which may have put them at risk of harm.

The RCOG maternity triage paper published in 2023 recommend at least two midwives to cover maternity triage services. This enables one midwife to be responsible for the initial assessment and the other midwife to carry out the subsequent care and investigations. The trust guidelines recommended 2 midwives on shift to cover triage during the day. Data supplied by the trust showed that staffing in triage did not consistently meet local guidelines with 2 midwives allocated to the day shift in triage 18.4% of the time between May to July 2024. Between May and July 2024, 100% of night shifts had one midwife working in triage. This is in line with trust recommendations but does not meet RCOG guidance.

Staff reported managers were having to work longer than permitted in the working time regulations (1998) due to the way the on-call pattern was arranged. The trust did not have an on-call policy which led to inconsistencies in payments and advice on compensatory rest required after working an on-call shift. This issue had been escalated and was included on the trust’s risk register.

Midwives told us that they needed additional resident doctor cover at night. The medical out of hours team covered both maternity and gynaecology services. This high workload may impact on their ability to respond to emergencies in a timely manner and we raised these concerns to the trust following the inspection.

Staff did not always have regular appraisals. Data provided by the trust showed that 66.4% of non-medical staff (e.g. midwives) and 72.3% of medical staff had completed their appraisal. This was below the trust’s target of 90% and was not included on their risk register. This was an on-going concern from the last inspection. Following the warning notice issued to the trust, an improvement plan for appraisal compliance was developed with a target of 90% compliance by the end of March 2025.

Women and birthing people we spoke with felt they were supported by competent staff, involved in decision making, and kept informed about their care. We found evidence that consent forms were being completed appropriately. Audits, submitted by the trust following the inspection, showed that gaining consent was taken seriously by staff. An audit looking at whether consent was gained prior to using instruments to assist with delivery found that it was documented 100% of the time.

Staff, including agency staff, bank staff, and volunteers were appropriately experienced and competent, and the skill mix of senior and more junior midwifery staff was appropriate. Managers requested bank staff familiar with the service and made sure all bank and agency staff had a full induction and understood the service.

The service had an induction process in place for staff. Staff reported they had access to additional training opportunities and support to help them, and said they were adequately trained for their role. The service had appropriate recruitment systems in place, for example disclosure and barring service (DBS) checks, to ensure the safety of women, birthing people, and babies.

The service did not assess or manage the risk of infection. Appropriate measures to manage risks to infection prevention and control were not carried out.

The maternity services were not always clean or well maintained. During the inspection we observed “I am clean” stickers in use in the maternity areas however, some stickers were out of date. We found stickers on 4 pieces of equipment in the birth centre which were dated 11 October 2024 which meant we could not be assured that all equipment was being cleaned after contact. There was a cleaning schedule in place and cleaners were observed regularly cleaning maternity areas, however mould was observed in the bathrooms on the postnatal ward, which was escalated to leaders. Following the inspection, improvements were made by the trust to treat the mould.

We identified other potential risks to infection prevention and control, for example torn and old mattresses in use on the postnatal ward. We also observed the roof leaking in the birth centre during inspection.

Staff were observed washing hands and adhering to “bare below the elbow” recommendations and dress code policy. Staff were aware of policies for infection prevention and control and were aware of the importance of hand hygiene. Similarly to the last inspection we found completion rates for the infection prevention and control mandatory training was below the trust target of 85%. Data from October 2024 showed compliance was 71.6% for doctors and 82.6% for midwives. We issued the trust with a warning notice to address this, and they aimed to achieve 90% compliance by March 2025.

Various infection control and prevention audits had been completed by the trust and the results were shared with us following the inspection. The saving lives hand hygiene audit tool was completed regularly in all in-patient maternity areas and showed high compliance with hand hygiene principles. In October 2024, staff on the postnatal ward achieved 98% compliance on the correct hand hygiene technique which was below the expected target of 100%. Staff achieved 100% compliance on the other three standards audited. Cleaning and decontamination audits were completed, however not consistently. For example, from August to October 2024 there are no recorded cleaning and decontamination audits for the birth centre. The perinatal quality surveillance model data presented to the quality committee in October 2024, highlighted the July and August 2024 cleaning audits did not reach the required level and an action plan was put in place including weekly meetings and biweekly spot checks.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities, and preferences.

Concerns around medicine storage and management were raised with the trust following the previous inspection and they were asked to make significant improvements. However, we found similar concerns during this inspection which meant the trust had not put sufficient improvements in place.

Staff did not always follow systems and processes to prescribe and administer medicines safely. The trust had an electronic prescribing and medicines administration system (EPMA) which had improved prescribing of medicines. However, during the inspection we found that the prescribing system was not always kept up to date. The system was not always updated when women and birthing people moved wards. There were examples of medication being left on the system when it was no longer required which placed women and birthing people at risk. Following the inspection and the warning notice, the trust reinforced the practice of deprescribing, and a plan was put in place to audit this process to monitor compliance.

On occasions we noted that women and birthing people missed doses of medications. This was escalated and staff reported this was often because medicines were unavailable. However, the reasons why medicines were not given was not always recorded. Missed doses of medications, particularly antibiotics and pain killers, can impact on the safe care and treatment of women and birthing people. We raised our concerns with senior leaders. Following this inspection, the trust told us they had introduced a new electronic patient record which allowed staff to order medications for individual patients that were not in stock on the maternity ward. They had also updated evidence collected as part of their accreditation process to audit this area.

Staff did not always store and manage medicines safely. Medicines including controlled drugs (CD), were stored securely, however water for injection and saline were not stored securely. We noted that CD management did not always meet the recommended standard and record keeping in CD books did not follow the trust policy. Following the inspection, the trust was asked to make a number of improvements in the storage of medications. As part of this, the service completed risk assessments and storage locations were reviewed.

We also found that the storage of some medicines required in an emergency was not in line with local or national guidance. For example, staff did not maintain a log of pre-prepared emergency medicine syringes raising concerns about their timely use within 24 hours. Following the inspection, the service changed their practice and emergency medicines were no longer pre-prepared. We also found some out of date medicines, as well as gaps in the daily checks of medicine fridge temperatures. Out of date medications or medications stored at incorrect temperatures may not be effective and therefore may put women, birthing people, and babies at risk of harm. Following the inspection, the service introduced a daily review of the maternity triage drug cupboard as part of the matron daily checklist.

The maternity Care Quality Commission (CQC) action plan which was updated in July 2024 stated that audits demonstrated improvements in medicines management and audits result was consistently above the 80% trust target. However, the CD check audit from April to June 2024, showed that this target was not met on the post-natal ward (77.3%). The target was met in the birth centre and the delivery suite (95% and 85.7% respectively).

Findings from the CQC maternity survey published in 2024, showed that service users gave an average of 6.7 out of 10 (10 being the highest) when asked about whether staff did everything they could to manage their pain after the birth of their baby. This was about the same when compared to other trusts.