Great Western 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 women were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination.

At our last assessment we rated this key question as requires improvement. At this assessment the rating has remained requires improvement. This meant people were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

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

We scored the service as 2. Lessons were not always learnt in a timely way to continually identify and embed good practice.

The risk and governance lead reported there had been a large focus on reviewing incidences due to several incidents remaining open. This was due to increased acuity within the maternity service, managers providing clinical support, staff absence, and the impact of industrial action.

At the time of the inspection there were 77 open incidents. There was a clear focus to reduce the number of overdue incidents. Governance meeting minutes confirmed there had been a reduction in the backlog month on month. To achieve this, the service introduced an incident review action plan to focus on the actions requiring completion. The action plan included timeframes and updates. The patient quality surveillance and assurance team (PQSA) reviewed actions and presented to the quality oversight group. However, despite this, this meant there was a delay in the service being able to take action to drive improve where required in a timely way.

Staff knew what incidents to report and raised concerns and reported incidents and near misses in line with the trust policy. Leaders shared learning from incidents by email, newsletters and during meetings. We saw themes and trends from learning were shared during handovers and safety briefings. The service used national risk tools, Patient Safety Incident Response Framework (PSIRF) and a Perinatal Quality, Safety Risk Framework to review and monitor risk.

The quality and safety team met regularly to discuss maternity performance and risk. Quality and safety meeting minutes showed incidents were reported on and key learning points were highlighted from incidents and shared. For example, the service had a perinatal learning forum where an incident was reviewed, clinical findings identified, learning and an improvement plan.

All high-level incidents were reviewed at the daily matron safety huddle within 24 hours of occurring. They were then shared with the ward manager and specialist midwives for further analyse and investigation. This meant any immediate safety actions could be addressed.

The perinatal mortality review tool (PMRT) was used to support objective and standardise local reviews of care when babies die. A mortality review was completed quarterly and reported at the quality and safety committee. The purpose of the review was to provide assurance to committee that mandatory requirements for mortality had been achieved by the trust. The PMRT report showed between October 2025 to December 2025 in all areas of the PMRT tool requirements had been met, with all perinatal deaths reported and reviewed within the appropriate timescales.

There were 6 incidents reported to Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries (MBBRACE) within 7 days of incident, and duty of candour was given to all families. MBBRACE is a national program focusing on improving maternal and infant health.

Between October 2025 to December 2025 the trust was compliant with all eligible standards for the maternity incentive scheme (MIS) clinical negligence scheme for trusts (CNST). The maternity incentive scheme was a financial incentive programme aimed at enhancing maternity and neonatal safety with NHS trusts. CNST provided requirements for trusts to use the PMRT to review all perinatal deaths within specific timeframes.

The service engaged with the Maternity and Newborn Safety Investigations (MNSI) programme. There were 2 incidences reported to the MNSI for investigation between August 2025 to January 2026. Patient safety investigations completed by the service identified where areas for improvement could be made, actions and a planned review date.

We scored the service as 2. The system for telephone triage did not always ensure people’s safety in line with guidance.

The service had a dedicated telephone triage line providing 24-hour cover. There was a dedicated office assigned to the telephone triage line to ensure confidentiality, which was located outside the maternity triage area to receive calls. This was in line with the Royal College of Obstetricians and Gynaecologists (RCOG) good practice paper. However, the telephone line was accessed on a portable telephone landline, and we found the midwife allocated was not always dedicated to just the telephone triage line but also supported in the maternity care centre when there was high acuity or short staffed.

RCOG’s good practice paper recommends the telephone triage line should be situated within a separate room to maternity triage and operated separately. This is to allow prompt and standardised initial assessment and the appropriate referrals. Following the inspection, the trust provided assurance the telephone triage midwife would be no longer support the maternity care centre. The telephone triage line continued to be on a separate line, and a portable telephone was no longer used, which meant a midwife had to be based within the designated room.

The CQC coordinates a national survey annually to look at the experiences of pregnant women and new mothers who used NHS maternity services. This survey looked at the experiences of pregnant women and new mothers who used NHS maternity services in 2025. This is coordinated by the CQC with other stakeholders and reported by the CQC. We reviewed the latest findings of the Maternity Services Survey 2025. We saw that when women were asked “Thinking about the last time you contacted the telephone triage line, did you feel that you got the advice you needed?”, the service scored 8.3, which was the same as the national average when compared to all other trusts in England. For the question “Thinking about the last time you attended triage face-to-face, did the midwife or doctor you spoke to listen to you?”, the service score 8.6, which was around the national average of 8.7.

Between March 2025 to August 2025 the service reported 20 red flags. Staffing red flags in maternity care can identify a lack of adequate maternity staffing, which can lead to unsafe care for women and their babies. The service had reported in November 2025 that there had been a reduction in red flags. Red flags may also occur due to staffing shortages, which can affect the ability to provide safe care. Between November 2025 to January 2026 there was only 1 red flag incident where the supernumerary status of the delivery suite coordinator was not achieved. The improvements made in the reductions of red flag event was reported to be likely due to the acute unit midwifery on call system now embedded into the service to minimise the impact of red flag triggers on service delivery.

All women were assessed by a midwife using a situation, background, assessment, recommendation (SBAR) tool. Handover and transfer of care was completed using the SBAR process and we saw examples throughout the inspection where the tool was used effectively by maternity staff.

Maternity key performance indicators measured the quality of care and outcomes for mothers and babies. The service monitored their performance through an electronic dashboard. The dashboard was reviewed and discussed monthly at the maternity governance meeting, with daily reviews of reported incidents.

The service had specialist midwives to support vulnerable women and consultant obstetricians were present for difficult births. Staff reported that it was easy to raise concerns and that they felt confident doing this. Staff had adequate training to respond to risks and were able to identify and act when women were at risk of deterioration.

The medical team had multiple board rounds throughout the day to review the care and treatment of women admitted, including women admitted for induction of labour or planned caesarean births.

The maternity service worked with the local maternity and neonatal systems (LMNS) to complete quarterly reviews on Saving Babies Lives Care Bundle (SBL). The SBL is a national tool designed to reduce still-birth rates.

The service was working at adopting the national maternity and neonatal care bundle in January 2026. The bundle was to focus on strengthening clinical pathways from early pregnancy through to the postnatal period. The approach meant the service would complete analysis of clinical pathways and complete a formal trust self-assessment to identify resources, training and pathway requirements, whilst benchmarking against national standards.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The service shared concerns quickly and appropriately.

The trust had appropriate safeguarding policies that aligned with national guidance and a designated safeguarding midwife. Staff understood and could describe how to protect women from abuse and could give examples which demonstrated their safeguarding understanding.

The trust had a daily safeguarding huddle, which was attended by the maternity safeguarding midwife. The safeguarding midwife also attended the ward daily to ascertain any safeguarding support required. Community midwifery teams received quarterly safeguarding supervision and acute staff could attend unplanned safeguarding supervision on the maternity unit.

A monthly safeguarding training compliance report was sent to the governance team and there was a standard operating procedure to review safeguarding training if it dropped below 80% compliance. Safeguarding training had been a focus due to previous compliance rates. The current rates of safeguarding level 3 adult and safeguarding level 3 children in January 2026 were 73% for midwives and 96% for obstetric staff. Safeguarding training was being adapted to align with the updated intercollegiate safeguarding guidance. The guidance focused on role specific safeguarding training. This meant the service compliance rate for safeguarding training was showing improvement and staff were projected to be compliant by May 2026.

Staff used safeguarding escalation pathways to identify and support women and complete safeguarding assessments if necessary. During a review of women’s maternity records, we saw staff asked safeguarding questions at each antenatal contact if safe to do so.

Staff placed a flag on women’s records if safeguarding issues were identified. This included staff in the emergency department and allowed staff to easily identify women or babies at risk.

Staff followed safe procedures for partners and families visiting the wards. The service strictly controlled access to all areas. Staff undertook baby abduction drills, so they knew what to do in the event of an attempted baby abduction. Staff told us abduction drills were completed yearly, and we saw governance meeting minutes which showed there were plans to complete abduction drills with and without the baby security tags.

We scored the service as 2. The evidence showed some shortfalls. 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.

The maternity care centre was an urgent 24-hour service to assess and treat pregnant women where there were urgent concerns. Following the previous inspection, the service, in February 2025 had moved the maternity care centre (maternity triage) from the delivery suite to the maternity outpatient area and the service became 24 hours. The move and the increase in hours were to improve the quality of care for women and to reduce the risk of not identifying the unwell woman in their pregnancy. Women arriving to the maternity care centre (MCC) were triaged using a nationally recognised tool to rate risks consistently. The current trust target was to review women within 15 minutes of arrival to the area by the midwife.

Although the maternity triage audit completed in January 2026 identified there had been an improved compliance rate since the relocation of maternity triage, due to the physical space of maternity triage the compliance continued not to meet the current trust target. Between October 2025 to December 2025, the compliance for women to be seen within 15 minutes by a midwife in MCC was 60%, this was below the trust target of 90%.

However, the service was mitigating the risk with monitoring the number of women seen to be seen by a midwife between 15 and 30 minutes which showed 97% of women were seen.

The trust currently used the modified early obstetric warning score (MEOWS) to monitor and identify risk. MEOWS was becoming outdated and the trust were due to move over to the updated version, maternity early warning score (MEWS) in March 2026. MEWS was reported to encourage a more holistic approach to maternal observations to support prompt recognition of the deteriorating woman.

However, the trust was continuing to use MEOWS and audits completed on the electronic notes system showed the service were well below the trust target compliance rate in all inpatient areas. With the antenatal compliance rate being 32.86% and the postnatal area was 48.72%. Senior leaders had reported the non-compliance was likely due to not having mandatory fields within the electronic recording of the tool. The service completed a paper audit which showed improvement, however, the outcome still identified areas of staff non-compliance with MEOWS documentation and continued to be below the trust target.

During our review of women’s records we saw staff documented when they identified a deterioration in women’s health and that risk responded to in a timely way. There is no evidence to suggest there had been any incidents associated with staff not fully completing the MEOWS documentation.

Following the outcome, the audit was added to the clinical audit tracker for further oversight and training was provided for staff. However, poor compliance continued meaning the mitigation to manage the risks was not effective. With the new tool being introduced, the governance lead had liaised with national MEWS leaders and early adopter trusts for further learning and support in adopting the new MEWS tool. To mitigate the risk of non-compliance the service reported that all fields within the new MEWS tool would be mandatory on the electronic system. This meant all elements of the MEWS would have to be recorded and completed. This was due to be introduced to the service in March 2026. A standard operating procedure for the new tool was in development, and staff had completed training to ensure understanding and compliance.

The trust reviewed Cardiotocography (CTG) monitoring and intermittent auscultation through completing hourly fresh eyes to gain reassurance of staff competence and completion. Cardiotocograph and intermittent auscultation was a method of fetal monitoring during labour that involves listening to the fetal heart with a doppler ultrasound.

‘Fresh eyes’ provide an independent and objective assessment, which is essential for improving patient safety, reducing the risk of errors in the interpretation of fetal wellbeing during labour, and supporting safe and timely clinical decision‑making.

The service completed a CTG monitoring in labour review, which showed between April 2025 to September 2025 the service was 85% compliant instead of the trust target compliance of 95%. The review found CTG’s which did not meet compliance, was due to the fresh eyes being delayed by a few minutes, or by missing 1 or 2 fresh eyes review during the whole process of monitoring.

The service reported they were completing ongoing work through the improving together project to improve fresh eye reviews. This included the production of a fetal surveillance education board with step-by-step process for documenting hourly and peer reviews. There were improvement huddles and ongoing fetal monitoring training for all maternity and obstetric staff. In January 2026 the compliance of fresh eyes had improved to 94%.

The service had a high dependency care pathway and were currently in the process of producing a standard operating procedure for high dependency care. The first draft was due for review in February 2026. Training and presentations relating to high dependency care had been provided through practical obstetric multi professional training (PROMPT) training. PROMPT is a training programme designed to improve the management of obstetric emergencies by enhancing the skills and knowledge professionals involved in maternity care.

The service had aimed to develop a high dependency team and had collaborated with ITU development leads and ITU consultant, however, this had not yet progressed. Although there was not a designated high dependency team, there were midwives who had completed the specific training and were competent to support high dependency women.

The trust was involved as an early implementer of the saving babies’ lives (SBL) care bundle and was continuing to implement the recommendations. SBL is an initiative aimed at reducing stillbirths and neonatal deaths through evidence-based practice.

The service had reported an ongoing trend in still births and were completing an internal review to ascertain themes and trends. Each case was evaluated for rapid learning and review of individual cases identified there were complex needs under limited opportunity to prevent deaths.

The still birth rate was reported through the safety report and included all pregnancy losses from 22 weeks, including termination of pregnancy for medical reasons. Each case was reviewed using the perinatal mortality review tool, with no reoccurring themes reported to be identified.

Monthly perinatal mortality review meetings (PMRT) included external services such as the maternity and neonatal voices partnership (MNVP). The findings from PMRT reviews were used to support continuous learning and service improvement, alongside provision of bereavement care.

Between August 2025 to January 2026 the trust reported 97 maternal readmissions, with the most common reasons of readmission being complications following childbirth, infection of obstetric wound and puerperal sepsis which is a severe bacterial infection occurring after childbirth.

The service provided a mini audit over the period of a month in March 2025 to assess the postnatal maternal readmissions requiring an inpatient stay over 24 hours. The audit showed there were 10 readmissions over the month with the most common causes being infection and blood pressure concerns. The audit identified at that time there was a declining trend in performance. There were only 30% of women reviewed by a consultant within 14 hours and consultant reviews within 24 hours declined to 50%. The audit, however, did identify that all of the women had received a daily clinical review by a doctor.

Following the audit the service identified the key recommendations were to improve the handover of postnatal readmission to highlight the risk status to the consultant. A poster was also displayed outside the delivery suite and in triage as a reminder for consultant to review all postnatal readmissions within 14 hours.

Staff told during the inspection that all maternal readmissions now received a consultant review within 14 hours, however, we were not provided with any further evidence to identify there had been an improvement since March 2025.

We scored the service as 2. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment or facilities supported the delivery of safe care.

The service provided a full range of maternity services, which included antenatal clinics, maternity care centre, day assessment unit, labour ward, obstetric theatre, midwifery led birthing unit and a bereavement suite. However, the design and the environment for some areas of the maternity unit did not effectively meet the needs of women and babies.

The physical space within the maternity care centre (MCC) was unable to meet the ongoing demands for women using the service, which meant there was capacity and workflow pressures. The waiting area for women attending the MCC was small with limited space for women and their partners.

The waiting area was next to a closed room where the MCC staff were situated. Within the room there was a desk where MCC staff were based and 2 very small separate treatment rooms for women. MCC staff could not observe women in the waiting area as the door was always closed. This meant there was a limited oversight of women which could lead to delayed recognition of a deteriorating woman. We were not aware of any incidents relating to a lack of oversight of women within the waiting area of the MCC.

Maternity leads were aware of the limited space and potential risks due to the environment, and this was recorded on the maternity risk register. The service had established a project group to explore potential environmental designs for the maternity triage area and was working with the estates team to ascertain whether designs were feasible.

The second obstetric theatre was non-compliant with current guidance due to the ventilation system not meeting the design criteria of an operating theatre. Therefore, the second theatre was only used in the event of an emergency. The trust was in the process of obtaining funding and a design team to create a functional second obstetric theatre. Although there was no timeframe as to when this would take place.

Community hubs had appropriate access to clinical facilities. Whilst some locations had experienced historical limitations, at the time of inspection all hubs had access to toilet facilities, and all clinical rooms had access to handwashing facilities, with the exception of one room where these facilities were available immediately outside the room. This room is only used to provide a vaccination service.

The delivery suite was observed to be cluttered in the corridor. However, other areas of the maternity unit were observed to be clutter free.

Staff completed daily checks on specialist equipment, including the post-partum and major obstetric haemorrhage trolley in the delivery suite. The emergency resuscitation trolleys were tagged.

Fire exits were clearly marked and unobstructed. There were birth pool evacuation nets and equipment in every room that had a birthing pool.

The service had a purpose-designed bereavement area to help support women and their families. The bereavement area was situated off from the delivery suite. The bereavement suite was well equipped and provided a comfortable home environment for women and their families.

Following feedback that women found it difficult to find the maternity area on the second floor, the trust were responsive and added colours to the flooring to identify where women needed to go.

We scored the service as 3. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service had completed a 6 monthly maternity staffing review as part of the quality and safety committee to gain assurance around staffing.

Midwifery staffing was reported to have improved over the last 6 months and staff we spoke to confirmed this during conversation. However, the leadership team reported staffing was always a challenge due to some vacancies, long term sickness and maternity leave.

Maternity staffing was reviewed using the national midwifery staffing tool Birthrate Plus (BR+) to calculate Midwifery staffing levels. The tool identifies the total midwifery time required to care for women on a 1:1 basis, throughout established labour.

The last BR+ report was completed recently in May 2025 and identified there was no additional increase in staff required.

The review identified that senior leads had increased the required level of midwifery staffing required on the BR+ tool to accommodate the increase in staff training required. The current recruitment plan was to ensure a there was a rolling recruitment process for newly qualified midwives with the aim to maintain staffing levels.

Staffing acuity rates in December 2025 showed they did not meet the required number of staff across the maternity unit. Staffing on the delivery suite was reported to be 75% and the birth centre had 96% acuity. Acuity was met only 34% of the time in Hazel the antenatal and postnatal ward. Leaders reported there were systems of escalation to support safety during increased acuity, with staffing reviewed daily and escalation to senior leadership during safety huddles. Staffing was supported by bank staff and redeployment of staff. Although staffing was low, the service continued to provide 1:1 in labour and there was the delivery suite co-ordinator was supernumerary 100%. However, the months before December 2025 showed staffing mostly met the needs of the service.

The quality and safety report for January 2026 reported an improvement in workforce data and staffing numbers was reported to have been mostly met. The report identified an improved staffing position with all areas of the unit mostly recruited.

The acute midwifery on call system was embedded into the service to minimise the impact of red flag triggers on service delivery. Between March 2025 to August 2025 the midwifery on call system was used 10 times. The acute midwifery on call system meant there was a reduction in the need to call community midwives into the unit, which meant there was a continued focus on the home birth service.

To support newly qualified midwives and improve retention an enhanced preceptorship programme was implemented. The enhanced preceptorship programme focused on a structured transition process for the midwife, introducing rotation around the service to provide varied experiences, support their preferences and offer more flexible working. Since the enhanced preceptorship implementation, the service had identified a reduction in turnover in newly qualified midwives, reducing from 13.8% to 1.3%. There was also a reduction in sickness for newly qualified midwives with the band 5 sickness being 12.23% in September 2024 to an improvement of 1.51% in July 2025.

However, across the maternity service there were a high number of sickness rates, with a high sickness level within community and triage teams. The service reported sickness rates appeared higher due to smaller teams and a high number of staff on long term sickness. Maternity ward and community managers were working with a trust wide working group to identify supportive steps for staff when receiving calls notifying of sickness and to welcome staff back following absence and a phased return.

There had been resources invested into obstetric staffing, with a registrar placed within the day assessment unit and a senior house officer (SHO) in the maternity care centre until 5pm.

There were plans for a further consultant to be recruited to the obstetric team to oversee maternity triage and fetal medicine. A dedicated consultant was already established within the labour ward, alongside a registrar and SHO. There was a separate obstetric team leading on the caesarean section pathway.

Medical staff told us there was no long-term gaps in the medical rota. Where there were short term shortfalls in staffing the team used locums for cover. Most of the locums worked regularly at the trust and all were up to date with their PROMPT and Fetal Monitoring training.

Maternity incentive scheme training compliance was monitored monthly and presented to the maternity governance, quality and safety committee. All maternity staff were above the target of 90% for the training other than anaesthetists, who were 88.98% compliant and maternity support workers who were 80% compliant. This was reported to be due to staff sickness.

The trust provided practical obstetric multi professional training (PROMPT) which was evidence based multi professional training package for obstetric emergencies. From December 2025, data showed that all staff were compliant with PROMPT training.

The service provided community specific PROMPT and fetal surveillance training following a request for further learning from community teams.

There were more vacancies within community teams. However, several maternity staff had expressed working within the community. The service was in the process of developing a 4 to 6 monthly community preceptorship supported by a band 7 buddy midwife to support the transition into community roles.

We scored the service a 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. Staff did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. However, we saw there was oversight and governance of cleaning schedules.

Hand hygiene reports for November and December 2025 showed the delivery suite did not meet the hand hygiene target with 84.6% compliance due to a lack of hand medical moisturiser available and the hand hygiene poster not being displayed at each hand-washing sink.

We found alcohol hand gel was not available outside each delivery room on the delivery suite.

Staff were seen not to be bare below the elbows, primarily on the delivery suite, with staff on the delivery suite seen wearing long sleeved tops under medical scrubs.

Following the inspection the trust was responsive and provided evidence to show alcohol gel was available outside every room, hand hygiene posters were added to every clinical area, and a prompt question had been added to the digital delivery suite multidisciplinary team handover form and completed twice daily. Staff were asked to have full understanding of the bare below the elbows policy and service leads completed on the spot uniform checks, which showed 100% compliance.

The service completed weekly infection control care bundle reports for the delivery suite and Hazel ward which met the trust compliance rate.

The service was part of preventing caesarean birth surgical site infection project. Following an improvement in preparation with antiseptic solutions prior to caesarean birth, data showed the number of surgical site infections had reduced since June 2025.

We scored the service as 3. The service made sure that medicines and treatments were safe and met women’s needs, capacities and preferences. They involved women in planning, including when changes happen.

The service had a medicine administration guideline for midwives. Midwives had access to the full list of midwives’ exemptions, so they were clear about administering within their remit.

Staff were trained to administer medicines safely. Staff demonstrated good understanding of how to monitor for and manage medical emergencies that can occur in pregnancy, including post-partum haemorrhages and sepsis.

The service used a paper drug chart system to prescribe and record administration of medicines. There were policies and procedures to support the safe and effective use of medicines. Staff completed medicines records accurately and kept them up to date. The Trust has an implementation plan for transfer to electronic prescribing in July 2026.