King's College Hospital

On this page

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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked 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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant that there were still aspects of the service that were not always safe.

The service was in breach of legal regulation in relation to risk assessments, records, medicines management, staffing, triage, safeguarding and equipment.

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.

There was not a consistent culture of proactively encouraging staff to raise safety concerns. Leaders did not always listen to staff concerns about safety. However, incidents were investigated by leaders.

Staff knew what incidents to report and understood the process for reporting incidents. However, most of the staff we spoke with did not feel encouraged and supported to raise concerns. Some staff reported they did not feel confident to raise concerns with some senior leaders. Post inspection we received a whistleblowing safety concern and conducted multi-disciplinary staff focus groups. Many staff who attended the focus groups said they did not feel encouraged and supported to raise safety concerns which impacted on patient safety. Following the assessment, the trust informed us that the recent 2024 staff survey results showed a slight increase in staff feeling they could raise concerns about unsafe clinical practice. However, their performance was still worse when compared to their 2021 performance and when benchmarked nationally. The service acknowledged that some staff may not feel confident to raise concerns. and there was ongoing work to improve this.

Managers reviewed incidents on a regular basis with the involvement of multidisciplinary staff so that they could identify potential immediate learning and actions needed. However, the service had a backlog of 30 incidents which were open over 60 days at the time of inspection, and not in line with the trust policy. The incidents were mostly related to the labour ward and post-natal ward.

Managers debriefed and supported staff after any incident. The service held weekly incident review panel to review incidents and agreed the appropriate incident response. Managers investigated incidents thoroughly. They involved women and their families in these investigations. Learning from recent incidents include escalation of CTG concerns to labour ward in a timely manner and learning from thematic review of third degree tears.

Managers shared learning with their staff about never events that happened elsewhere. Never Events are serious, largely preventable safety incidents that should not occur if the available preventative measures are implemented. The service had 1 never event in October 2024 for a retained swab during delivery. The trust had recently undertaken swab safety audits, where the swab safety results for each month in 2024 were over 75%. The trust had implemented learning since the last never event that occurred in October 2024 of retained swabs, where an after-action review was completed. The recommendations included strengthening staff induction and training in swab management, considering a video of good practice and rotation to theatres to observe surgical scrub nurses’ practice.

Lessons were learned from safety incidents, resulting in changes that improve care for others. For example, following a never event on retained swab in October 2024, an after-action review was completed which included recommendations on strengthening staff induction and training in swab management and rotation to theatres to observe surgical scrub nurses’ practice. The trust developed a swab safety checklist on their electronic record and implemented a delivery swab and perineal repair swabs needle count. The learning from the never event was shared with staff via emails, newsletters and handover meetings. The service had developed a bitesize safety video on labour ward, implemented swab safety stars initiative and carried out a presentation in March 2025 for cross site staff around the learning from the never event. The service had also worked with South East London Local Maternity and Neonatal System (SEL LMNS) task and finishing group and was involved in the safety swab campaign to reduce and prevent never events relating to retained swab in the region to drive improvement.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always make sure care was provided in line with guidance. There were ongoing breaches in completing risk assessments, telephone triage, and prioritising women in triage. This was not an improvement from the last inspection.

Staff did not always complete risk assessments for each woman on arrival and review these regularly. Staff used an evidence-based, standardised risk assessment tool for maternity triage. The triage and maternity assessment unit (MAU) waiting time audits highlighted concerns around the timely prioritisation assessment, correct prioritisation rating documentation and delays in obstetric review in MAU.

The service did not have a dedicated Telephone triage line 24/7 cover. The triage telephone line was located in a private area away from the triage area and staffed by 1 midwife during the day however out of hours this was covered by triage midwives in the triage area. The triage telephone line provision out of hours was not in line with the Royal College of Obstetricians and Gynaecologists (RCOG) good practice paper which advised that maternity service should ensure calls are taken outside the clinical area in a dedicated and protected quiet space to ensure confidentiality by a midwife whose duties at that time are solely for telephone triage.

The September 2024 to March 2025 telephone assessment line audit showed that 39% of calls were answered and while 61% of calls were unanswered by staff. This meant that women were unable to seek advice when they needed it and there were delays in assessing the needs of women. There were also delays in women accessing appropriate support from suitably qualified staff. The recommendation from the audit was that the service should consider investing in a system that can improve call handling and record keeping. It was unclear whether any actions are being taken to address this recommendation. Following the assessment, the trust provided us with recent audit data, which showed an improvement in compliance. From May to October 2025, over 80% of call were answered by staff.

We reviewed the maternity triage waiting times for review audit for July 2024 to March 2025. This identified midwives reviewed 72% of women within 15 minutes of arrival and 83% of women were reviewed by doctors within the expected time frame. A prioritisation rating was assigned 44% of the time and a correct prioritisation rating was assigned 76% of the time. Whilst service had improved the 15 minutes wait time compliance to 75% they were still not meeting the trust target of 90%.

Triage did not have a dedicated lead and there was a lack of oversight on triage provision and performance by senior leaders. Senior staff told us the labour ward coordinator was the lead for triage however triage staff were not aware the labour ward matron was their lead for triage and were unclear who to escalate concerns to.

Staff told us the senior leaders changed the triage telephone service provision from a 24/7 service to a 12.5hrs service and for a staffing of 2 midwives to one midwife per shift and they now handled the nonurgent calls for the sister site. Staff felt the change in the staffing and service provision was not adequate and managers had not considered the complexities and diverse needs of women who called the telephone line. These changes to staffing and hours of operation contributed to significant delays in call answering and risked delayed assessment of urgent case.

Post assessment, the trust confirmed that these changes followed a full consultation process between June and August 2024. The decision was informed by workforce data, staffing exercise modelling, and activity analysis, which demonstrated low overnight call volumes and identified opportunities to redeploy staff to areas of higher acuity. The trust told us that changes to the telephone assessment line were implemented following an equality impact assessment process and staff consultation, with adjustments made in response to feedback to ensure safe and effective service delivery.

From July 2024 month to March 2025, the MAU waiting time audit showed midwives reviewed 61% of women within 15 minutes of arrival and 77% of women were reviewed by doctors within the expected time frame. A prioritisation rating was assigned 45% of the time and a correct prioritisation rating was assigned 89% of the time. The medical cover for the MAU, which was located offsite was from 1pm to 5pm, Monday to Friday. Between the hours of 8am and 1pm, MAU medical review was covered as part of the antenatal ward round. Outside these hours, anyone who needed a doctor's review was asked to go to triage. This impacted the timely doctor review of women. The MAU was relocated to the main site after the assessment as part of a previously planned move.

The August 2024 to January 2025 risk assessment in pregnancy audit result showed that only 63% of women were risk assessed when they presented to MAU, triage and antenatal clinic. This increased the risk of harm to women, birthing people and babies. However, the compliance on the completion of 4 other risk assessments standards ranged between 76% to 93%.

The service had developed an action plan in early 2025 to improve compliance in triage waiting times. The action plan included a review and relocation of the MAU to the hospital by the end of April 2025, which was completed successfully in May 2025. Post assessment, the trust told us MAU now had a dedicated medical cover from 9am to 5pm and extended consultant presence through concurrent obstetric clinics. Recent audit data showed minimal attendances outside these hours, and from November 2025, the service plans to extend MAU hours to 8.30am to 6.30pm to further support continuity of care. Managers were also looking at how the electronic system can flag the prioritisation rating and monitoring of medical staffing during the daily ward rounds. We have not reviewed the impact of this change. Post assessment, the electronic record system has been enhanced to support the prioritisation tool documentation to distinguish between MAU admission and triage admission. We have not reviewed the impact of this change. Leaders told us that targeted training was available to staff and compliance will be monitored through regular audits.

There were significant gaps in the completion of the risks assessments and prioritisation of women in patient records, for example, there were number of fields not recorded consistently in the triage attendance book. Staff told us the prioritisation tool was not effective and therefore they don’t always document this in the patient record. It was unclear what the service was doing to improve compliance.

All babies should receive appropriate feeding support. The neonatal readmission audit showed that only 63% of babies had feeding support during their initial admission documented in their records against the 90% trust target. It was unclear whether any actions are being taken to address this issue.

Staff did not always complete fetal monitoring risk assessments in line with national guidance. Staff did not always use the fresh eyes approach to carry out fetal monitoring safely and effectively. Leaders audited how effectively staff monitored women during labour having continuous cardiotocograph (CTG). The ‘fresh eyes’ audit for October 2024 and March 2025 showed clear escalation, interpretation and management plans following CTG and staff did ‘fresh eyes’ at each hourly assessment in 70% of cases. During inspection we reviewed 10 CTG records, which showed full compliance in only 8 records. Gaps in compliance with fetal monitoring protocols posed a risk of delays in the recognition of fetal distress. This also raised the service compliance with the Saving Babies’ Lives Care Bundle.

Staff did not always follow up-to-date policies and processes that align with other key partners involved in patient care. This was not an improvement from the last inspection. At the time of inspection, the trust reported that they had 121 maternity guidelines cross site, 87% of these guidelines were in date at the time of inspection. There were 13% of guidelines that were overdue for review, and this was not on the risk register. Senior staff told us there were plans in place to review the out-of-date guidelines. The trust had audit, quality and patient safety midwives who had oversight of guidelines. They reported that all the out-of-date guidelines had a plan for completion, and we observed guidelines being discussed regularly at maternity governance meetings. Staff were also kept apprised on recently reviewed and/or new guidelines via the monthly Clinical Governance newsletter, ensuring staff were aware of and adhering to the latest guidance.

Shift changes, safety huddles, ward rounds and handovers included all necessary key information to keep women and babies safe.

The service provided transitional care for babies who required additional care.

There was no safeguarding policy specific to maternity services. The service did not always follow up to date safeguarding guidance. However, staff understood how to protect women from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.

There was no maternity specific safeguarding policy and staff referred to the trust safeguarding adults' and children safeguarding policy, which was not always relevant. In addition, this policy was out of date and had not been reviewed since May 2023. The service accessed the trust wide safeguarding adult policy which was in date. This meant maternity-specific safeguarding risks, such as perinatal domestic abuse and safeguarding of unborn children, was not explicitly addressed in policy guidance. The absence of a maternity-specific safeguarding policies and the overdue review of the trust-wide safeguarding children policy represented a continued shortfall from the last inspection. Following the assessment the trust confirmed the maternity safeguarding policy was now a stand-alone policy. The policy has been ratified and is available on the trust intranet.

Staff received training specific for their role on how to recognise and report abuse including female genital mutilation. We were not assured around the training content and if it was in line with current guidance as the safeguarding adult’ and children’s policies were out of date. Following the assessment, the trust provided us with information which showed the safeguarding training content was in line with current national guidance. The level 3 safeguarding training syllabus and training have been reviewed and benchmarked against national standards. Training records showed that 91% staff had completed their safeguarding trainings. Data showed that 92% staff had completed both Level 3 safeguarding children training and 84% had completed the Level 3 safeguarding adults training at the level for their role as set out in the trust's policy and in the intercollegiate guidelines. Staff had achieved 97% compliance on the Level 1 safeguarding training and 85% on the level 2 training.

Staff could give examples of how to protect women from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff understood the importance of supporting equality and diversity and ensuring care and treatment was provided in accordance with the Act. Staff gave examples which demonstrated their understanding and showed how they had considered the needs of women with protected characteristics.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them. Staff asked women about domestic abuse, and this was document on the patient records system. Where safeguarding concerns were identified, women had birth plans with input from the safeguarding team.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. The service had a safeguarding team including a safeguarding midwife who staff could turn to when they had concerns. Care records detailed where safeguarding concerns had been escalated in line with local procedures.

Staff followed safe procedures for children visiting the ward.

Staff followed the positive identification and abduction management policy and undertook regular baby abduction drills. The maternity ward had security measures in place to prevent baby abduction and staff were aware of their policy and process.

The service did not always work well with 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.

Staff did not always assess each woman’s health when admitted, informed them of risk and how to keep themselves safe. Staff did not always know about and deal with any specific risk issues. This was as a result of gaps in the completion of risk assessments such as venous thrombosis (VTE) and fluid balance charts. Following the assessments, the trust provided evidence to show that the service now prioritised observational audits and clinical reviews to ensure staff completed risk assessments for women. Recent targeted staff training and validation audits have addressed documentation issues, with the latest audits, such as VTE, showing marked improvement.

Data showed that staff achieved 41% compliance on the fluid balance chart audit and 79% compliance in the VTE audit between the months of October 2024 and March 2025. The incomplete VTE risk assessments meant there may be a delay in administering prophylaxis or treatment, therefore, increasing the risk of preventable harm. Staff also achieved 79% compliance on the individualised care plan audit and 85% compliance in the documentation audit.

We reviewed 10 patient records and observed risk assessments were not always completed at every contact in 7 patient records and vitamin D was only documented in half of the records reviewed. The service provided additional information after the assessment, explaining that the variation in Vitamin D documentation was due to non-standardised fields in the electronic record system before November 2024, making entries hard to identify. Since the assessment, the service reported improvement in completion of risk assessment because of an update of the digital electronic patient record system. For example, the Q2 2025-2026 Vitamin D audit showed 100% compliance.

Staff used a nationally recognised tool such as Maternity Early Warning Score (MEWS) to identify women at risk of deterioration. However, there were gaps in the completion of MEWS charts. Data showed that staff achieved 77.2% compliance in the MEWS audit between the months of October 2024 and March 2025. During inspection, we reviewed 6 MEWS chart and found staff correctly completed them on 2 records. The incomplete MEWS charts meant the service could not be assured staff were detecting and escalating deteriorations in conditions appropriately or effectively.

Staff completed newborn risk assessments when babies were born using recognised tools and reviewed this regularly.

Between April 2024 to March 2025, data showed that 7 babies were born in triage (72%), antenatal ward (14%) and lift (14%) during a transfer to the labour ward. Senior staff told us this was mainly related to women going unexpectedly delivering within 30 minutes of arrival. The service had pathways and escalation processes in place to minimise the risk of unplanned births in non-labour ward areas. Staff told us when women went into precipitated labour and delivered in an inappropriate area of the service, they ensured their privacy and dignity was maintained.

We observed staff completed the World Health Organisation (WHO) 5 steps to safer surgery checklist prior to starting surgical procedures. From January to March 2025, staff achieved 97% compliance in the World Health Organisation (WHO) surgical checklist audit.

The service had a central CTG monitoring in place in line with national recommendations.

From October 2024 to April 2025, the service reported 8 neonatal readmissions, which were mostly related to jaundice. During the same timeframe the service reported 54 maternal post-natal readmissions, which were mostly related to neonatal readmission, infection and hypertension.

Women and their families could give feedback on the service and their treatment and staff supported them to do this.

The service had relevant information supporting people to live healthier lives.

Staff supported women and birthing to make consent and informed decisions about their care.

Staff made sure women living with mental health problems, learning disabilities and dementia, received the necessary care to meet all their needs. The service had perinatal mental health midwives to support women with their mental health.

Staff completed, or arranged, psychosocial assessments and risk assessments for women thought to be at risk of self-harm or suicide. Staff gave women and those close to them help, emotional support and advice when they needed it.

Staff used the SBAR (Situation Background Assessment and Recommendation) algorithm 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 98% compliance against the trust target of 90%.

Staff did not always make sure equipment supported the delivery of safe care. This was not an improvement from the last inspection. However, the service detected and controlled potential risks in the care environment.

The service did not always have enough suitable equipment to help them to safely care for women and babies. Staff told us they did not have enough equipment such as sonicaids, blood pressure machine and wheelchairs on the wards. The lack of blood pressure monitors which caused delay’s in undertaken clinical observation for women and babies. Post assessment, the trust told us no incidents had been reported due to equipment unavailability. However, staff did not always feel safe to raise concerns around environment and equipment. The trust informed us that there was an ongoing investment in and monitoring of equipment to ensure safe care for women and babies. The community centre we visited now had emergency equipment on site to safely care for women and babies. This was an improvement from the last inspection.

Staff did not always carry out daily safety checks of specialist equipment. The trust had made some improvements in the management of equipment checks since our previous inspection in August 2022. However, we still observed gaps in daily checks of equipment, emergency equipment and found out of date items. For example, there were gaps in the daily checks of emergency resuscitation trolley and resuscitaire on labour ward and maternity wards. We found 2 out of date surgical gowns with expiry dates August and December 2024 in the adult resuscitation trolley on the labour ward and maternity wards. We escalated this to senior staff, and they told us this should not be in the emergency equipment as they used them during the COVID pandemic. We found out of date items in the neonatal resuscitation box in the maternity assessment unit and when escalated to staff we were told this equipment should not be in the unit. We were concerned that the gaps in the daily checks and audits of emergency equipment had not identified by staff and senior managers. Therefore, we were not assured checking processes within the service were effective despite an audit of emergency equipment between January and March 2025 showed 94% compliance.

We observed 23 gaps in the daily checks of the breastmilk fridge from February to April 2025. The breastmilk fridge temperature audit showed 66% compliance. This posed a risk of bacterial contamination and spoilage, which can reduce the nutritional quality of the breast milk and potentially harm babies if the fridge was not monitored.

We also observed equipment which had not been serviced in accordance with the trusts own policy. There was a set of baby weighing scales and a syringe driver that had not been serviced since June 2022. We escalated this to senior staff and this was replaced immediately.

The design of the environment followed national guidance. The maternity unit was fully secure with a monitored entry and exit system.

The service had suitable facilities, to meet the needs of women's and their families.

Staff regularly checked birthing pool cleanliness and the service had a contract for legionella testing of the water supply.

Women could reach call bells and staff responded quickly when called.

Staff disposed of clinical waste safely. Sharps bins were labelled correctly and not over-filled. Staff separated clinical waste and used the correct bins. They stored waste in locked bins while waiting for removal.

There was system in place to monitor the nitrous oxide (mixture of gas and air which provides rapid pain relief) level in line with the Health and Safety Executive (HSE) recommendations. The trust had a nitrous oxide waste reduction quality improvement in place to reduce workplace exposure to nitrous oxide.

Oxygen and Nitrous Oxide Cylinders were handled and managed securely, this was an improvement from the last inspection.

There has been improvement since the last inspection and the toilets and bathrooms had ligature free call bells and pull cord lights.

The service opened a new bereavement room in 2024 which was sound proofed, appropriately furnished, designed and fit for purpose to support bereaved women, birthing partner and their families. This was an improvement since the last inspection.

The service met control of substances hazardous to health (COSHH) standards.

The service did not always make sure there were enough qualified, skilled and experienced staff. Staff did not always make sure staff received effective support. However, staff worked together well to provide safe care that met people’s individual needs.

The service did not have enough midwifery staff on every shift to keep women and babies safe. The number of midwives and healthcare assistants did not always match the planned numbers. On the second day of inspection, we noted that the ward was short of 2 midwives, recovery was short of 1 midwife and while MAU was short of 1 midwife and a maternity care assistant. Post assessments, the trust told us there was escalation in place with twice daily staffing huddles and the management of acuity using the staffing exercise App and 1 to 1 care in labour was maintained to ensure the safety of women and babies. We also noted that one of the matrons was on sick leave, the community team did not have a matron and there was no governance lead or band 8 named safeguarding midwife in the service. Following our assessment, the trust told us the service had recruited a community matron and a governance lead who started on 28 April 2025, and the position was vacant for 5 months. The gap in roles was supported by members of the senior midwifery leadership team. The safeguarding leadership was maintained with an interim cover provided by a named children’s nurse who was also a registered midwife with support from the associate director of safeguarding. However, during our onsite visit, majority of staff were not aware of the interim cover arrangement for the vacant roles.

The service monitored and reported maternity ‘red flag’ staffing incidents in line with National Institute for Health and Care Excellence (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 October 2024 to March 2025, there were 41 red flag incidents reported for the service and mainly related to delay between admission for induction of labour (IOL) and start of IOL (34%), delayed or cancelled activity (20%) and coordinator supernumerary (20%). The red flags were also reported on the learn from patient safety events (LFPSE).

The service had increasing turnover rates for midwifery staff. As of December 2024, the service reported 15% turnover rate for community and practice midwives and 13% turnover rate for labour ward staff. This was against the trust target of 13%. Senior staff reported good feedback from exit interviews and 65% of staff that had left the service had commented they will return or recommend others to work for the service.

The service had increasing sickness rates for midwifery staff. As of December 2024, the service reported 8% sickness rate for community and practice midwives and 9% sickness rate for labour ward staff, against the trust target of 3.5%. However, sickness rates for medical staff were low.

Staff were generally up-to-date with the trust wide mandatory and maternity specific trainings. However, not all resident doctors, midwives and maternity support workers were up-to-date in their maternity specific training modules.

The service did not always make sure that staff received multi-professional simulated obstetric emergency training. The trust data showed an overall 84.1% compliance in the PROMPT training against the trust target of 90% as of 7 April 2025. We note that the resident doctors and midwives met the trust target. However, the anaesthetic resident’s low compliance was 67% due to rotation into the maternity unit in February 2025. Post assessments, the trust told us anaesthetic trainees had been booked for training in April and May 2025. Post assessment as part of the factual accuracy process, the trust provided us with training data, which showed improvement in the PROMPT training. The June/July 2025 training data showed compliance was 95% for obstetric anaesthetic trainees and 91% for obstetric anaesthetic consultants.

Training data showed poor compliance with the pool evacuation training. As of 7 April 2025, 42% for midwives and 26% for labour ward support workers had completed this training. We escalated our concerns with senior staff and were told the hospital had an action plan in place to improve compliance by prioritising training for midwives and maternity support workers (MSWs). The service had scheduled additional training dates from 14 April to 21 July 2025 for pool evacuation training and simulations for midwifery staff.

Managers supported staff to develop through yearly, constructive appraisals of their work. The appraisal rate for staff was 74% as of 7 April 2025, which was below the trust target of 90% but reflected progress within their appraisal window. Following the assessment, as part of the factual accuracy process, the trust provided evidence which showed that the staff appraisal rate was 87%, which was below the trust's target of 90%. We have not reviewed the impact of this change. The service also supported staff development through appraisals and with access to professional development opportunities and training programmes.

Staff told us staffing had improved since the last inspection however there were occasions where there were short of midwives on the wards. There was 5 whole time equivalent (WTE) vacancy in the maternity wards at the time of inspection. Staff across the maternity unit told us a pay cut in bank rates had impacted on the shift fill rate in recent months. Post assessment, the service acknowledged staff concerns regarding the change in bank rates and the impact on individual income. The trust told us the change in bank rates was a trust-wide initiative introduced in June 2024 to align with the London sector, which was communicated to all staff and Q&A session held with the chief nurse. The trust said the changes have not impacted on the shift fill rate and safe staffing was maintained, with ongoing monitoring, regular reporting to the board, workforce planning and recruitment initiatives.

Nursing and midwifery rotas were prepared and published eight weeks in advance, and weekly reminders were sent to those with authorisation to finalise them. Medical rotas operated on a rolling 12-month cycle. Staff allocation was dynamic and responsive to real-time acuity and absences, ensuring a safe skill mix and adequate shift coverage to ensure safety and continuity of care. However, both midwifery and medical staff described the rota management and staff allocation as ‘chaotic and inconsistent’ depending on the managers relationship with staff which had impacted on staffing and covering of shifts and culture in the service.

Staff reported limited career development and lack of opportunity for external training due to a lack of funding. This resulted in some staff paying for their own training. However, information received from the trust following the assessment showed that the service offered a wide range of funded career development and external training opportunities. However, some staff have successfully accessed leadership, academic, and clinical development programs, such as the Capital Midwife program.

From January to March 2025, the service reported an overall 91% fill rate for midwifery staff during the day and night shifts. We noted that the antenatal ward was where there were mainly gaps in shifts particularly at night however the fill rate had improved from 52% in January 2025 to 86% in March 2025.

The service completed a maternity safe staffing workforce review in line with national guidance in November 2024. This review recommended 232.89 whole-time equivalent (WTE) midwifery staff Band 3 to 7 compared to the funded staffing of 251.95WTE, a positive variance of 19.06WTE staff. However, there was a shortfall of 4.26WTE for non-clinical additional specialist and managerial roles in comparison to the birth rate plus recommended establishment. It was unclear whether the trust planned to uphold this uplift to staffing.

The ward manager could adjust staffing levels according to the needs of women with the use of an acuity tool and by deployment of staff to areas of high acuity. However, staff expressed concerns around the skill mix of staff and lack of enough band 6 and 7 staff on the labour ward which affects supervision of junior staff, complex case management and leadership on shifts.

The service had clinical practice facilitators that supported the preceptor midwives. However they were not always available on each shift particularly on Wednesdays. Staff told us this impacted on the skill mix and over reliance on the labour ward co-ordinator and band 6 midwives. Following the assessment, the trust told us that the ward managers and other specialist midwives also supported the preceptor midwives.

The service had reducing vacancy rates for midwifery staff and increasing vacancy rates for medical staff. The service had recently employed 17.64wte (whole time equivalent) midwives which were mostly band 5 between January and April 2025.

There was a supernumerary shift co-ordinator on duty for every shift and covered 24 hours a day who had oversight of the staffing, acuity, and capacity. A practice development team supported midwives. The team included 10 practice development lead midwives and student practice facilitator. The team had a vacancy for a student practice facilitator.

The service had a safety and flow midwives on every shift to maintain patient flow and safe staffing in the service.

Managers limited their use of bank and agency staff and requested staff familiar with the service. Managers made sure all bank and agency staff had a full induction and understood the service.

The high dependency unit (HDU) staff we spoke to have had HDU training, which was an improvement from the last inspection.

The service employed 26 obstetric consultants and there was 98-hour consultant presence cover on the labour ward Monday to Friday from 7am to 9pm and 9am to 9pm on weekends. There was on call arrangement in place for out of hours. The service also employed 2 GP trainee doctors, 11 SHOs, 13 speciality doctors and 14 senior registrars. The labour ward doctors also covered the co-located triage from 7.15am to 7.15pm, 7 days a week. There was consultant and SHO cover for antenatal and postnatal wards. The service always had a consultant on call during evenings and weekends.

The service had reducing turnover rates for medical staff. From April 2024 to March 2025, the service reported 0.9% turnover rates for consultants and 3.7% for resident and middle grade doctors. The turnover rates for anaesthetic doctors which included the hospital theatre care groups was 7.4%, against the trust target of 13%. From April 2024 to March 2025, the service reported an average 1.6% sickness for medical staff. From April 2024 to March 2025, the service reported 14% average vacancies for consultants, 19.4% for resident and middle grade doctors, 0.4% for anaesthetist. This was against a trust target of 10%. Following the assessment, the trust provided us with data which showed that as of April 2025, the trust vacancies for obstetricians was 3.5% (1.41WTE).

The service had low rates of bank and locum medical staff. Managers could access locums when they needed additional medical staff. Managers made sure bank, agency and locums had a full induction to the service before they started work. The anaesthetic rota was compliant with Anaesthesia Clinical Services Accreditation standard 1.7.2.1 and the maternity service had a dedicated anaesthetist 24 hours a day, 7 days a week to cover labour ward for elective and emergency caesarean sections. The service employed 12 obstetric anaesthetists and had on call anaesthetists’ arrangement in place for out of hours.

The medical staff matched the planned number. The service had a good skill mix of medical staff on each shift and reviewed this regularly. Staff told us they had good medical cover however allocation for medical staff could be unfair and chaotic at times.

The mandatory and maternity specific training were comprehensive and met the needs of women and staff. The training included but was not limited to practical obstetric multi-professional training (PROMPT), fetal monitoring, infection control, cultural competency and perinatal mental health.

As of April 2025, 97% maternity staff had completed the cardiotocograph (CTG) and human factors training. Staff also achieved 95% in their data security awareness training and 93.3% compliance both on their newborn life support training and perinatal mental heath training.

Managers and the practice development team monitored mandatory training and alerted staff when they needed to update their training.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. They kept equipment and the premises visibly clean.

Ward areas were clean and had suitable furnishings which were well-maintained.

The service generally performed well for cleanliness. The maternity areas displayed cleanliness ratings of 4 or 5 stars. Daily cleaning was completed by domestic staff and maternity support workers. Cleaning records were up-to-date and demonstrated that all areas were cleaned regularly.

Staff had clear roles and responsibilities around infection prevention and control.

Staff followed infection control principles including the use of personal protective equipment (PPE). Data showed hand hygiene audits were completed regularly in all maternity areas. From January to March 2025, staff achieved 99.8% compliance. This was an improvement from the last inspection.

Staff cleaned equipment including couches after patient contact and labelled equipment to show when it was last cleaned.

Women we spoke to spoke positively about the environment and felt it was clean, safe and hygienic.

The service control and isolation measures in place to care for women, birthing people and babies with suspected or confirmed infections.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. This was not an improvement from the last inspection and a repeat breach of regulation. However, staff involved people in planning, including when changes happened.

Medicines were not always stored or managed appropriately. We found out of date medicines and gaps in the daily checks of fridge and ambient temperature where medicines were stored in the maternity units. For example, we found 26 out of date temazepam controlled drugs (CD) tablets with expiry date, March 2025 in the antenatal ward. We also found 17 out of date medicines that expired in February 2025 in the MAU neonatal resuscitation box such as adrenaline, sterile water and sodium chloride syringe.

On the labour ward, we found some medicines were stored in the CD cupboard which were not logged in the CD book register. We found 109 tablets of Cytotec 200mcg misoprostol, which is a drug that required 2 midwifery checks. Post assessment, the service confirmed misoprostol is not legally a controlled drug but was treated as such under trust policy for safe custody and governance. Therefore, the misoprostol tablets found were stored correctly in the CD cupboard and did not need to be logged in the CD book. We also found 27 tablets of codeine phosphate stock medicines in the CD cupboard which was not recorded in the CD book register and in line with the trust policy. A midwife told us the codeine phosphate might be a patient own medicines however no patient name was seen on the packaging. This was not in line with best practice and trust policy.

Staff across the maternity service did not regularly monitor the fridge and ambient temperature where medicines were stored in line with the trust policy. There were 35 gaps noted in fridge and ambient temperature checks on the labour ward from June to December 2024. We also observed 37 gaps in the ambient temperature checks and 14 gaps in the fridge temperature checks on the wards from January to April 2025. Hospital data showed 89% compliance in the fridge temperature checks audit for the period of October 2024 to March 2025.

From 01 April 2024 to 3 March 2025, the hospital reported 57 patient safety medicines incidents in the maternity service. There was an increased medicines incidents reported in November 2024. We saw these were related mainly related to women being discharged without the required medicines and staff giving too little drug dosage. We saw that medicines incidents were investigated, and learning identified with action plan in place to drive improvement. This includes training and simulation exercise for staff around labelling of intravenous medicines and safety alerts. The service had also held a recent medicines management culture week to reduce medicines related safety incidents.

Staff followed systems and processes to prescribe and administer medicines safely. The medicines and controlled drugs policies were comprehensive and in date.

Staff reviewed each woman’s and birthing person’s medicines regularly and provided advice to women and carers about their medicines. Staff completed medicines records accurately and kept them up-to-date. Staff followed national practice to check women had the correct medicines when they were admitted or they moved between services.

Women were appropriately involved in decisions about their medicines.

The service ensured women’s ’s behaviour was not controlled by excessive and inappropriate use of medicines.

Staff learned from safety alerts and incidents to improve practice.

The service had access to the pharmacist team who provided support such as medication reconciliation, reviewing prescriptions and dispensing medications.