Princess Royal University Hospital Also known as Farnborough 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 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.

At our last inspection we rated this key question requires improvement. The service was in breach of safe care and treatment, premises and equipment and good governance. At this assessment the rating remained unchanged. This meant that there were still aspects of the service that were not always safe.

The service was in breach of the legal regulation safe care and treatment relating to risk assessments and infection prevention and control. These were continued breaches from the previous inspection.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The service had a proactive and positive culture of safety and lessons were learnt to continually identify and embed good practice.

Staff we spoke with knew what incidents to report, how to report them and felt encouraged doing so. The trust reported that managers debriefed and supported staff after any serious incident as part of the after actions review (AAR). Lessons were learned from safety incidents and complaints, resulting in changes that improved care for others. Staff reported that they received feedback from incidents reported. Feedback on incidents reported by the individual was provided via email and shared with the wider team via team meetings, handovers and safety huddles. We observed learning from incidents, being discussed at various handovers, huddles and meetings.

The trust had 1 ‘never’ event in maternity which involved a retained swab during a delivery, the trust did not specify at which site the incident occurred. However, we saw evidence of shared learning cross-site. In response to the ‘never’ event a patient safety incident investigation (PSII) was commissioned. Data provided by the trust showed evidence of the incident being discussed at safety huddles, governance meetings and information being emailed to staff via message of the week. The trust also reported working in collaboration with other trusts within the Local Maternity and Neonatal System (LMNS) to share learning regarding swab safety.

The LMNS is a partnership between the service and relevant stakeholders within Southeast London. The system worked to develop and transform maternity services in response to local needs and national recommendations.

As of January 2025, the governance team had been producing governance newsletters. We saw this displayed on the unit and staff reported they also received it via email to aid learning. The newsletter included information on risks, incidents, audits and updates on guidelines.

The service did not work well to establish and maintain safe systems of care. They did not always make sure care was provided in line with guidance.

During the assessment it was observed that the Maternity Assessment Unit (MAU) had too many functions which resulted in delays in attending to women. Most women attending the maternity unit were triaged via the MAU. The MAU also handled scheduled appointments from 8am to 5pm and operated the telephone assessment line which was also located here.

The MAU was staffed by 3 midwives. One midwife oversaw scheduled appointments, which included women requiring additional surveillance (e.g., for raised blood pressure). Two midwives were responsible for face-to-face triage and managing the telephone triage line. This was not in line with the Royal College of Obstetricians and Gynaecologists (RCOG): Maternity Triage, Good Practice Paper which states, that the telephone triage line should be covered by a midwife whose duties at the time are solely for telephone triage. Staff told us it was difficult to manage the multiple functions of the MAU. This risk had been added to the risk register and in response, the trust introduced a new call-handling system as of 1 April 2025 to reduce the volume of calls managed directly by the service. Urgent calls which included calls about pain, bleeding and reduced fetal movements were managed by MAU at the service. Whilst non-urgent calls which included calls about test results, infant feeding or general pregnancy concerns were diverted to the maternity unit at Kings College Hospital, which had a dedicated telephone triage midwife solely on the day shift. Lastly the service had introduced a labour line which was managed by midwives on the Oasis Birth Centre at the service. Staff reported that as this was a very recent change, they could not assess whether this reduced the number of calls.

We also observed that there was not always a clear separation between women attending MAU for scheduled appointments and those attending for triage. This meant that there was not always clear oversight and triage midwives did not always stick to their dedicated role as set out by a recognised electronic triage tool. The service informed us post assessment that their staffing rotas clearly identify dedicated staff to triage and MAU and that the pathways, oversight and electronic tools worked to safeguard the intended distinction between the two areas and maintain dedicated roles for triage midwives. An action plan had been developed in response and the service also reported that they now actively monitor gaps in compliance through monthly audits which were reviewed at daily safety huddles.

Staff did not always complete risk assessments for women on admission in a timely manner. The service used the triage tool to assess women on arrival. The triage tool is a system used to assess how quickly women presenting with pregnancy related concerns should be seen, based on their clinical need. Prioritisation was undertaken using a red, amber, green (RAG) rating system and then recorded on the electronic patient record (EPR) system. According to the tool and local policy women should be seen by a midwife within 15 minutes of arrival and prioritised as either red, orange, yellow or green. Each colour identified how soon women should be reviewed by a doctor or midwife as required. A red rating required immediate transfer to labour ward, orange required a review within 15 minutes, yellow required a review within 1 hour and green required a review within 4 hours.

During the assessment we noted that there were delays in women being reviewed which therefore caused breaches of the tool and policy timings. This was not an improvement from the last inspection however, there was now a dedicated doctor for the maternity assessment unit. This cover was Monday to Friday from 9am to 5pm however, due to space constraints the doctors were not always physically in the area requiring midwives to bleep them to attend. On weekends and overnight the maternity assessment unit was covered by the on-call team who also covered the rest of the unit. Staff we spoke with reported that delays were often due to high acuity and delays getting a doctor to review women especially after 5pm and on weekends.

The service supplied triage audit data for January to March 2025. Data showed that compliance with the 15-minute initial midwife review was 83%, RAG rating being assigned was 96%, correct RAG rating being assigned was 59% and only 30% of obstetric reviews occurred within the triage tool and policy recommended timeframe. This did not meet the trust target of 100% compliance and aligned with what we observed during the inspection.

The service created an action plan in April 2025 in response to the audit data. This included allocation of obstetric input, cross-site staff training, ongoing electronic patient record documentation support, twice daily consultant ward rounds and support to be provided from the elective team during times of high acuity. Ongoing work included regular audit of the triage tool performance and review of any incidents. The service had 5 outstanding actions at the time of the assessment and reported that some of the key actions had been completed by October 2025, with the remaining improvements still ongoing.

Triage documentation was not always completed contemporaneously. During the inspection, we noted that staff were not always completing the triage whiteboard. The triage white board was a part of the service’s triage tool system and a visual aid to all staff on triage. Information on the board included but was not limited to women’s names, location, arrival time, RAG rating. The board should have been updated contemporaneously; this not being done could potentially affect oversight of activity on MAU. However, we noted that midwives documented accurate timings on the EPR system, and the service also had a safety and flow midwife on each shift. The safety and flow midwives were supernumerary and had oversight of patient flow across the whole service, this was an improvement since the last inspection.

We also noted that not all midwives answering the telephone assessment line followed the trust proforma available on the EPR system. According to midwives this was due to high acuity on the unit or a lack of available computers which led to them documenting retrospectively. The proforma was in place to ensure all midwives asked women the appropriate questions during the phone call, to properly assess whether they needed to attend the unit. Not using the proforma contemporaneously meant that midwives could potentially omit necessary questions on the proforma. It was also unclear whether all midwives on the Oasis birth centre were using the proforma when triaging labour line calls. This was escalated to the trust, and they reported that they would increase learning on this especially for midwives on the Oasis birth centre as the labour line had only recently been introduced.

Women's notes were comprehensive and stored securely. The service had an EPR system that all relevant staff had access to, which meant there were no delays in staff accessing women’s records when they moved to a new team or area. Staff had access to women’s historic notes, current notes, risk assessments and diagnostic results. Staff we spoke to reported that the system was comprehensive and easy to navigate. However, midwives in the community reported that due to signal issues in some children centres they could not always access the system via their laptops. This meant they had no access to previous records and were not able to document at the time of the appointment. This resulted in an increased workload as they had to document retrospectively. This had been identified on the risk register and the service was trialling alternate service providers to increase connectivity. Community midwives could also download the EPR application on to their work phones to gain access and document.

Staff did not always follow up-to-date policies. 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. 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.

Staff had training on how to recognise and report abuse, and they knew how to apply it. The service worked well with other agencies to do so. However, the service did not always follow up to date guidance.

The service had relevant safeguarding policies in place however, they were not always in date. The trust wide safeguarding children and young people policy was due for review in May 2023.This meant we could not be assured that staff followed up to date guidance to keep women and babies safe.

The safeguarding team was made up of 2 safeguarding lead midwives, with each lead covering each maternity unit and also working cross site and a band 7 specialist midwife. Staff reported that the limited size of the team was a challenge due to the amount of complex safeguarding cases seen on both Kings College Hospital and Princess Royal University Hospital sites. In response to this the safeguarding lead reported that they worked closely with the trust safeguarding team and aimed to empower all midwives to action safeguarding concerns.

Domestic violence was one of the main safeguarding themes at the service. The safeguarding lead reported a good working relationship with the Independent Domestic Violence Advisers (IDVA).

All staff received training specific for their role on how to recognise and report abuse. The service provided nursing and midwifery staff with level 3 safeguarding training for children and adults which was facilitated virtually by the trust safeguarding team. At the time of inspection, the compliance rate for midwifery staff was 91% overall, which exceeded the trust target of 90%. The service provided medical staff with level 2 safeguarding training for children and adults. It was unclear why medical staff were not trained at level 3. At the time of inspection, the compliance rate for medical staff was 90% overall which met the trust target of 90%.

Staff reported that they knew how to make a safeguarding referral and who to inform if they had concerns. Staff could give examples of how to protect women from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff also knew how to identify adults and children at risk of, or suffering, significant harm and knew where to document and access this information. Staff reported that the safeguarding team was very visible and could identify who the safeguarding lead was.

The maternity ward had security measures in place to prevent baby abduction. Staff were aware of the baby abduction policy which was in date and undertook baby abduction drills. The trust reported that the last baby abduction drill took place on 1 August 2024, whereby staff followed the policy expectations. The abduction was not successful, however the service still identified learning which has been shared with the staff.

Staff provided care to meet people’s needs. However, staff did not always complete fetal monitoring risk assessments in line with national guidance.

Staff did not always complete fetal monitoring risk assessments in line with national guidance. During labour, high-risk women were attached to a cardiotocograph (CTG), which is a piece of equipment used to monitor fetal heart rate and uterine contractions. According to the national institute for health and care excellence (NICE) guidelines NG229, women attached to a CTG during labour should have an hourly fresh eyes review of the trace produced by the CTG. Hourly fresh eyes require two clinicians to review the trace and document their findings during the intrapartum period to ensure the baby is safe to continue with labour. This documentation is done via women’s EPR. Audit data showed only 40% compliance with the requirement for hourly ‘fresh eyes’ review between the months of October and December 2024. The service did not identify what the trust target was.

The service had an action plan to improve compliance which included increasing sessions of fetal monitoring and fresh eyes. The service also purchased several handheld devices with the electronic patient records app installed to be used on delivery suite. This was introduced to ensure fresh eyes were documented at the time of the review as it was highlighted that lack of computers led to clinicians forgetting to double sign the fresh eyes.

During the assessment we did not observe the use of centralised cardiotocograph (CTG) monitoring on labour ward. Centralised CTG monitoring would allow staff to have access to CTG monitoring in all labour ward rooms to enhance oversight from the obstetric team. Staff reported that this was due to connectivity issues that the service was currently working on. The trust reported post assessment that the labour ward had been equipped with a centralised cardiotocograph (CTG) surveillance system since April 2024. However, it had been relocated to a different area during the assessment, as the original location room was being refurbished.

Staff assessed whether each woman and birthing person was high or low risk at booking and reviewed this at each antenatal appointment. This was done to ensure women received the appropriate care.

Staff used a nationally recognised tool to identify women at risk of deterioration, the service used maternity early warning score (MEWS) chart to document women’s observations. MEWS charts we reviewed were completed, scored and escalated appropriately if required. Audit data provided by the trust showed 100% compliance in the use of MEWS charts and escalation between the months of January and March 2025. Staff also completed venous thromboembolism (VTE) scoring in the notes of women we reviewed onsite.

Staff completed newborn risk assessments when babies were born using recognised tools and reviewed this regularly. Staff risk assessed each newborn at birth to identify if they required regular observations. Staff then used neonatal early warning trigger and track (NEWTT) charts to document neonatal observations for babies who required it. NEWTT charts we reviewed were completed, scored and escalated appropriately if required. The trust did not provide audit data for the compliance of the use of NEWTT charts. The service provided transitional care for babies who required additional care, this was managed by a neonatal nurse and support worker.

Staff completed the World Health Organisation (WHO) 5 steps to safer surgery checklist prior to starting surgical procedures. The WHO checklist is a set of priority checks to ensure women’s safety before, during and after a surgical procedure. WHO checklists we reviewed were completed appropriately. Audit data provided by the trust showed 100% compliance in the use of the WHO checklist between the months of January and March 2025.

We observed good multidisciplinary working. Handovers and safety huddles we observed across the unit involved all relevant members of the multidisciplinary team, were structured and were held in an area with minimal disruptions. Shift changes and handovers included all necessary key information to keep women and babies safe.

The service did not always detect and control potential risks in the care environment. Staff did not always make sure equipment, facilities and technology supported the delivery of safe care.

The design of the environment did not always follow national guidance. The unit was open 24-hours a day, 7 days a week. Maternity services at the hospital consisted of a maternity assessment unit (MAU), birth centre, labour ward and maternity ward.

Space in the maternity assessment unit was limited and held too many functions including the telephone triage line in the same clinical area as triage. The trust reported that from auditing the number of women attending MAU, they were assured that the physical footprint is sufficient to meet the needs of the service. However, the area was still not in line with RCOG: Maternity Triage, Good Practice Paper that states that calls should be taken outside of the clinical area in a dedicated and protected quiet space.

The waiting area for the maternity assessment unit had 7 seats which staff reported was not always enough and was located outside of the unit. This was also not in line with RCOG: Maternity Triage, Good Practice Paper that states that the waiting area was adequately sized and ideally visible to clinical staff. The limitation of the waiting area had been identified on the risk register and the service had installed CCTV of the waiting area to improve oversight.

The unit was fully secure with an entry and exit system monitored by ward clerks and maternity staff. On both days of inspection, the entry and exit system were not functional due to a system failure however, security presence was sourced to cover the doors 24 hours a day. During the inspection, we observed entry to all areas within the service being operated appropriately by staff. We observed ward clerks questioning inspectors and visitors to prevent tail gating and unauthorised visitors.

The labour ward had a dedicated ligature free room which they used for women with mental health concerns. However, a comprehensive ligature risk assessment had not been completed for the unit in line with policy requirements. According to trust policy this should have been carried out every 12-24 months or more frequently if significant changes occur. We did however observe a broken blind pull in triage that could present a ligature risk.

Birthing partners were supported to attend the birth and provide support to women in all areas within the service. The service had bereavement facilities in the event of fetal loss. The bereavement room had adequate facilities to meet the needs of families however, it was not soundproof and was directly opposite the induction of labour bay. This was not in line with the national bereavement pathway recommendations which recommends women should have dedicated, soundproofed bereavement rooms or suites where parents can have complete privacy and comfort.

The service had enough equipment to help them to safely care for women and babies. This included but was not limited to CTG monitors, Sonicaids and observation machines. However, we found out of date consumables in clinical areas across the unit. This included 19 sodium citrate blood vials in the neonatal trolley on the maternity ward. This was escalated to the midwife in charge and the items were removed from the clinical area.

Staff had access to enough emergency and safety equipment and mostly carried out daily checks on them. Emergency equipment included but was not limited to neonatal resuscitaires, adult resuscitation trolleys, post-partum haemorrhage (PPH) trolleys, eclampsia trolleys and glucometers. We observed minimal gaps in emergency and specialist equipment whilst onsite. Audit data supplied by the service showed 85% compliance on delivery suite, 99% compliance on the maternity ward and 97% compliance on the birth centre between the months of January and March 2025. The service had an action plan to improve compliance which included increased oversight by matrons and senior staff, and compliance related emails to be sent out to required staff.

Women could reach call bells, and we observed staff responding quickly when called on the maternity wards. Staff disposed of clinical waste safely, we observed sharps bins being filled within a safe limit and clinical and domestic waste being segregated and labelled correctly.

The service made sure there were enough qualified, skilled and experienced staff. Staff worked together well to provide safe care that met people’s individual needs.

The service had enough midwifery and medical staff to keep women and babies safe. During the assessment the numbers of midwives, maternity support workers and medical staff matched the planned numbers in all areas, except labour ward. Labour ward was short 2 midwives due to sickness, however due to low acuity this did not impact on patient safety. The service had a good skill mix of medical staff on each shift and reviewed this regularly. The service reported that they always had an obstetric and anaesthetic consultant on call during evenings and weekends.

The service had a safety and flow matron and a team of safety and flow midwives on every shift. The safety and flow midwives were supernumerary and had oversight of the staffing, acuity, and capacity within the unit. They adjusted staffing levels and skill mix daily according to the needs of women.

The service used birth rate plus acuity tool to calculate the number of midwives needed on the maternity unit. Midwives in charge carried out the calculation 4 hourly on the intrapartum areas of the unit and 6 hourly on the maternity ward. The service commissioned a midwifery workforce exercise by birth rate plus which was published in November 2024. Findings from this exercise showed that the funded establishment for clinical staff bands 3-7 was adequate with a positive variance in comparison to the birth rate plus recommended establishment. However, there was a deficit in the current funded establishment for non-clinical specialist and managerial roles in comparison to the birth rate plus recommended establishment. In March 2025 the midwifery staffing was reviewed after financial investment. This showed that the trust was established to the recommended requirement set out by the birth rate plus staffing exercise, which included non-clinical specialist and managerial roles.

The service had a cross-site safety huddle twice a day. The cross-site safety huddle we observed was coordinated by the safety and flow matron and covered topics such as staffing, acuity levels, safeguarding and any incidents. The service also had site specific safety huddles which was coordinated by the safety and flow midwife and attended by staff from the obstetric, anaesthetic, quality and safety and neonatal teams. This safety huddle covered staffing, acuity levels, safeguarding, concerns in each area, discharges and learning from previous incidents. We observed evidence of good multidisciplinary working at these huddles.

There was also a safety huddle on the maternity ward which was coordinated by the ward manager, midwife in charge or safety and flow midwife. Each clinical midwife on the ward gave an update on their workload and all appropriate checks of safety equipment were discussed.

The service monitored maternity ‘red flag’ staffing incidents in line with NICE guideline: Safe midwifery staffing for maternity settings. A midwifery ‘red flag’ event is a warning sign that something may be wrong with midwifery staffing. The service recorded 157 red flag events in the last 6 months, mostly linked to delays in induction of labour. One to one care in labour and the labour ward coordinator maintaining supernumerary status was always maintained. The service undertook an audit of this data to identify the causes of red flag events and were currently working to reduce delays. Staffing deficits and high acuity had been identified on the risk register and the service reported that they were proactively recruiting in response.

The trust had increasing vacancy, turnover and sickness rates cross site. The overall vacancy rate for maternity staff was 9.9% in October, 9.6% in November and 13% in December 2024, against a trust target of 10%. The overall voluntary turnover rate for maternity staff was 10.8% in October, 10.9% in November and 14.2% in December 2024, against a trust target of 13%. The overall sickness rate for maternity staff was 5.9% in October, 7.8% in November and 7.6% in December 2024, against a trust target of 3.5%.

The service reported that they used regular bank and agency midwives who were familiar with the service and made sure all bank, agency and locum staff had a full induction and understood the service

The trust did not provide vacancy, turnover or sickness data for medical staff however, medical staff we spoke with reported good staffing levels.

The trust provided maternity specific and statutory mandatory training that was comprehensive and met the needs of women and staff. Midwifery staff were compliant with their training requirements. The training included but was not limited to infection control, equality and diversity, adult basic life support, newborn life support, maternal medicine and practical obstetric multi-professional training (PROMPT). Overall compliance for maternity specific and statutory mandatory training was 90%, which met the trust target of 90%.

Medical staff also received and kept up to date with their maternity specific and statutory mandatory training. Overall compliance for training was 93%. This exceeded the trust target of 90% which was an improvement from the last inspection.

The practice development team monitored midwifery and medical mandatory training. Staff we spoke with reported that they were automatically booked on to training when this was due.

Managers supported staff to develop through yearly, constructive appraisals of their work. Data from the service showed 88% compliance with appraisals for midwifery staff, against a trust target of 90%. The trust did not provide appraisal compliance rates for medical staff or identify what the trust target was.

Staff had clear roles and responsibilities around infection prevention and control however, they did not always follow them.

Ward areas were clean however, the furnishings were not always well-maintained.We observed couches in the triage that were cracked and torn. Daily cleaning was completed by domestic staff and maternity support workers. Domestic staff had a cleaning schedule that they followed and an up-to-date cleaning record to demonstrate all areas were cleaned regularly. The service met control of substances hazardous to health (COSHH) standards. Staff cleaned equipment after patient contact and labelled equipment with green ‘I am clean’ stickers to show when it was last cleaned.

The service generally performed well for cleanliness. The service provided cleaning audit data from January to March 2025. The overall compliance for birth centre was 99%, labour ward was 99% and the maternity ward was 97%.

During the assessment we noted a lack of alcohol rub available at points of care. The service provided infection prevention and control audit data across the unit from January to March 2025. The overall compliance for the unit was 93% however, compliance with the availability of alcohol hand rub was only 71% which coincided with what we found on inspection. The service had an action plan to improve compliance which involved monthly audits and implementation of a restocking system.

Although trust audits between January and March 2025 showed staff compliance with hand hygiene, our observations did not align with these finding. We observed poor compliance with hand hygiene across the unit, this included lack of hand washing before and after patient contact. We observed staff wearing nail varnish and false nails, contrary to infection control guidance. We escalated our observations to the trust, and they believed that these observations were isolated cases. However, they reported that they would continue to audit hand hygiene monthly and reinforce the policy at handovers and mandatory training. They also reported that improvement actions were discussed at Maternity Quality Governance meetings.

We did however observe staff following infection control principles in relation to the use of personal protective equipment (PPE).

The service made sure that there were systems and processes in place to manage medicines and treatments safely.

Staff completed medicines records accurately and kept them up to date. Medicines were prescribed directly on to drug charts on the electronic patient record system. We reviewed 7 medicine charts and found that allergies and weights were always documented to ensure medicines were prescribed safely. Staff followed systems and had access to relevant reference material to safely prescribe and administer medicines. Medicine charts were fully completed by staff when administering medicines.

Staff stored and managed medicines safely. Controlled drugs (CD) (medicines requiring additional control due to the potential of misuse) were stored securely. CD on labour ward were locked in an electronic medicine storage unit that only staff can access via fingerprint or password. According to the trust policy-controlled drugs stored in the medicine storage unit should be checked at least once a week and every 72 hours if the medication has been used. The CD count was correct during the assessment and data provided by the trust showed that CD were being checked in line with trust policy.

Room, fridge and freezer temperatures where medicines were stored were monitored and staff, we spoke with understood when to escalate. Medical gases were also stored safely.