Basingstoke and North Hampshire 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

Staff were kind, caring and compassionate. Women using maternity services could access care and treatment when they needed it.

Leaders had taken steps to improve the reporting, monitoring and managing of incidents. There was an improved culture of safety and learning. There was a clear system to investigate incidents and to identify learning.

A national recognised risk review tool was used within the Day Assessment Unit (DAU) and maternity Triage.

The service had a standard operating procedure (SOP) and flow chart for maternity clinical escalation. Staff felt confident they could escalate concerns to leaders, and they felt listened too.

There had been significant improvement in providing staff with feedback following incidents and the service had launched a Maternity, Quality and Safety team (MQuEST). Monthly MQAS team meetings were in place for staff to talk through recent incidents and share learning.

The service had introduced two continuity teams across the local areas covered by the trust to support vulnerable women.

Between January 2025 to June 2025 data showed areas of some poor compliance in staff completing Maternity Early Obstetric Warning Score (MEOWs). The service reported the reason for low compliance in some areas was due to not all fields of data being completed by staff. The director of midwifery told us the service was in the process of improving the electronic monitoring of MEOWS and there had been no adverse outcomes for women because of the missing fields of data.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant women 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.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service used a maternity patient safety incident reporting pathway to investigate incidents and to identify learning. Incidents were triaged daily by the maternity quality and assurance and safety team. Immediate safety actions identified following triage were discussed at the maternity and neonatal rapid review meeting and then triaged into the appropriate review pathway. These meetings were held twice weekly.

There had been significant improvement in providing staff with feedback following incidents and the service had launched a Maternity, Quality Education, Safety together (MQEST). Monthly MQEST team meetings were in place for staff to talk through recent incidents and share learning. The monthly meetings were added to all staffs mandatory training with the expectation that all staff attended at least 1 session per year and staff told us they were encouraged to present their own cases at the meeting.

An incident review meeting was held weekly, where 5 recent incidents were discussed.

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 and a maternity message of the week was shared during safety huddles we attended.

The maternity safety team sent out a quality Maternity Safety Newsletter to improve communication and learning from incidents. The newsletter provided information on current maternity audits, learning from incidents, staff reminders and staff suggestions on improving safety within maternity.

Evidence showed the service used actions from feedback from women and local incidents to form part of the maternity specific training. Data showed the service had a higher number of incidents for women experiencing long delays during the induction of labour (IOL) process. Following a review of IOL incidents and feedback on women’s experiences regarding delays, the trust approved a quality improvement (QI). An antenatal midwife led on improving the information sharing for IOL’s and an IOL steering group was set up for the ongoing monitoring and improvement of the IOL process within HHFT. There had been ongoing improvement in providing women with information through an IOL online information board called a padlet.

The service set up an antenatal and postnatal forum to focus on areas of improvement and worked with the maternity and neonatal voice partnership (MNVP) to outline the purpose, scope objectives, roles and responsibilities of the forum.

The service was working to improve support for women who had experienced birth trauma and had introduced trauma informed mandatory training for all maternity staff.

The maternity service worked with women and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

Following our last assessment the service had developed clear clinical guidelines for the triage system. They were also in the process of improving the day assessment unit and triage.

The day assessment unit (DAU) and maternity triage had moved upstairs in February 2024 closer to the labour ward to support safe escalation. This meant the midwife working within DAU could access support from colleagues if required to manage the needs of women as well as access the medical team. The service had also changed triage, so it was open 24 hours, 7 days a week.

The service used a nationally recognised risk review tool within maternity triage, used to improve the safety of mothers, babies, and the management of the department. It consisted of an assessment of women when they presented with unexpected problems or concerns, and then a standardised way of determining the urgency that they needed to be seen.

All women were assessed by a midwife using a situation, background, assessment, recommendation (SBAR) tool. SBAR compliance was monitored through monthly audits.

The service had made improvements to maternity triage since our last inspection. More staff were allocated to maternity triage and there was an increase in opening times, including weekends to support the demand of women attending the service. The service completed monthly audits to determine how long women waited for further assessment and if required, a medical review.

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 outcome of these was also discussed at maternity performance meetings, with any learning shared as part of the weekly safety bulletin.

The maternity lead for DAU and triage told us data collated from using the risk review tool were shared quarterly at the monthly maternity governance meeting. There was a focus on ensuring women were appropriately triaged by staff within 15 minutes of arrival. Audit data showed that in June 2025, 549 women attended triage and 89.3% were seen within 15 minutes of arrival, which was over the trust target of 85%

The timings of non-urgent medical reviews did not have a mandated timeframe set by the risk review tool and the trust had set its own target for medical non-urgent review. Data showed for June 2025 that 4 out of the 8 women requiring a medical review within the timeframe set by the trust of two hours were not seen within that timeframe.

The service had a standard operating procedure (SOP) for maternity clinical escalation. The SOP identified the key steps to support clinical escalation and there was a flowchart to support decision making. Staff told us they felt confident they could escalate concerns to maternity leaders, and that they would be listened to.

The medical team held multiple board rounds throughout the day where the care and treatment of women admitted was discussed and those due for admission for their labour to be induced or planned caesarean births.

The labour ward consultant and coordinator prioritised inductions of labour (IOL) dependant on clinical need and plans were updated in records of care.

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 provided the implementation progress for the trust’s maternity service between 2024 to 2025 was found to be compliant with targets.

The provider worked with women and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving women’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff understood and could describe how to protect women from abuse and could give examples which demonstrated their safeguarding understanding. Staff had training on how to recognise and report abuse, and they knew how to apply it.

The service provided safeguarding training for maternity and obstetric staff. There was a clear maternity safeguarding children’s guideline and following our previous assessment the trust had in place a pathway for domestic abuse.

As part of the maternity safeguarding specific training the service gave attendees specific case studies to work through. We saw case studies on how to identify and follow up domestic abuse, bruising on babies and teenage pregnancy.

The service had introduced Oak continuity team to support vulnerable women. The criteria for referral were for women to be new to the country, including refugees, asylum seekers, those with mental health issues, black and minority ethnic women who had any vulnerability, previously looked after child or any woman which had a specific vulnerability that requires extra support.

To provide continuous support to the women they worked with, the team attended a high number of safeguarding meetings with Children's Services. The community matron told us this had supported the community midwifery team by increasing community team’s capacity by around 300 hours.

Training records showed both midwifery and obstetric staff were above the 90% compliant with safeguarding level 3 training.

The service had made improvements since our last inspection. There were safeguarding alerts added to the electronic records with a clear summary regarding safeguarding concerns. During a review of women’s records we saw all women were asked safeguarding questions during each antenatal contact. This meant women were given every opportunity to disclose abuse and staff could identify any potential risks.

The service had a clear Maternity Safeguarding Policy, which was to be used in conjunction with the trust Safeguarding Children’s Policy.

The service did not always have full oversight to manage all risks. However, senior leads were working to identify themes and trends to improve care for women and we did not see any incidents relating to these areas. Staff mostly provided care to meet women’s needs that were safe, supportive and enabled women to do the things that mattered to them.

During the assessment we found there was low compliance and a lack of oversight of maternity audits. This meant there was a potential failure to identify and manage risks.

The service only provided the audit data for May 2025 for women having a situational, background, assessment and recommendation (SBAR) tool completed during handover from intrapartum to postnatal care. The audit showed there was only 50% compliance.

Leaders recognised poor compliance during SBAR audits and had developed an action plan for managing maternity audits.

The maternity early obstetric warning scoring system (MEOWS) was a tool used to aid early recognition and management of deteriorating women. Antenatal and postnatal care showed areas of poor compliance between January 2025 to June 2025 in staff completing MEOWs scores. The reason for low compliance was due to not all fields of data being completed by staff. This meant staff could miss or not hand over specific information to support the safe care of women and their baby which could increase the risk of unsafe care and lead to poor outcomes.

The Director of Midwifery (DOM) told us the service was in the process of improving how staff complete the electronic monitoring of MEOWS and reported there had been no adverse outcomes for women.

The service monitored outcomes through saving babies’ lives (SBL). Local maternity and neonatal systems (LMNS) had declared the trust compliant in all but two elements of saving babies lives (SBL) which were partially compliant. Where the elements were partially completed the trust completed a deep-dive and a manual audit to check compliance.

As part of the upcoming change and most updated version of SBL, the trust had taken the opportunity to adopt the new approach and had recently started to move away from monitoring fresh eyes to monitoring babies with arterial blood gases below the normal range. Monitoring arterial blood gases also came from the trust review of the hypoxic ischaemic encephalotomy (HIE) cases. This was reported and discussed monthly at the maternity governance meetings and learning was shared with staff.

Hypoxic ischaemic encephalopathy rates were monitored closely, and the trust had seen a reduction of cases.

The service had completed standardised theatre audits across HHFT. This incorporated the national safety standards for invasive procedures and to improve safety and consistency of how they measured the World Health Organisation (WHO) surgical safety checklist. The WHO surgical checklist audit showed the service did not meet trust compliance and were poor in adding data to surgical team briefs and debriefs. To improve the consistency of data between the trust maternity locations the service was trialling a standardised audit. The aim of the audit is to improve consistency, compliance and shared learning.

The trust continued to review Cardiotocography (CTG) monitoring and fresh eyes to gain reassurance of staff competence and completion. The data received showed that CTG interpretation and escalation was mostly accurate. The main theme identified following the review was documentation of labour care by obstetricians required improvement as there was a lack of detail within the information recorded. However, the service was working with obstetricians on the improvement of documentation.

All midwifery and obstetric staff attended mandatory training and completed a CTG and intermittent auscultation (IA) assessment yearly. The service had met the trust compliance in CTG audits, and they reported fetal monitoring was not a theme in trust maternity and neonatal safety investigations.

The service had achieved all 10 of the core safety actions in the NHS Maternity Incentive Scheme (MIS). MIS was designed to improve the quality of care for women, families and newborns. Actions included providing staff training, completing pregnancy and birth data and reporting poor outcomes to the Maternity and Newborn Safety Investigations team for independent review.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service had made improvements to the maternity environment. The maternity triage area had recently moved to be on the same floor as the labour ward, following our previous assessment. This was to provide a clear flow from maternity triage to labour ward.

The whole maternity unit was clean, tidy and free of clutter. Fire exits were clearly marked and unobstructed.

Staff completed daily checks of specialist equipment. Records showed these checks had been consistently completed. The baby resuscitation equipment is checked twice daily (once per shift).

The service had made improvements on their entry and exit system into the maternity ward. The maternity unit was now found to be secure with a monitored entry and exit system, and the service had completed baby abduction drills. There was a separate bell for women to access maternity triage, so that the ward could review who entered the maternity unit.

Checks on the adult resuscitation and emergency trolleys were fully completed.

Staff disposed of clinical waste safely. Contaminated waste was segregated correctly and stored securely while awaiting disposal. Sharps bins were assembled correctly and not over filled.

All equipment and store cupboards were visibly clean, tidy, and uncluttered and there were birth pool evacuation nets and equipment in every room that had a birthing pool.

The provider 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 women’s individual needs.

There were significant improvements on staffing numbers since our previous assessment. The trust ensured staffing levels were managed across the midwifery service to improve the safety of women and their babies.

The trust listened and worked well with maternity leaders to improve staffing significantly across the maternity service. Staffing templates were reviewed across all acute sites, and there was an increase in staffing numbers to meet the needs of the higher birth rates within the trust.

Triage and the day assessment unit continued to be combined, however, the unit had been moved to be closer to labour ward to support at risk women.

Midwifery on-call shifts were changed from 4 to a maximum of 6 per year to support the demands of the service.

Practice development midwives worked with new staff or inexperienced staff to develop their knowledge and in skills within the labour ward. This meant, they were supported to develop their skills and competence within the labour ward.

The service was at full establishment for obstetric staffing.

To support the increase of women choosing planned caesarean birth the service had recruited additional registered general nurses as well as providing an extra early shift midwife. This meant that there was less pressure on labour ward midwives to support women post operatively.

The Maternity service had 20 episodes where the maternity unit required support due to either the high number of women attending the service, high level of need or staffing issues across both obstetric sites during May 2025. The escalation policy was used, and appropriate actions were taken to support the service. During each episode of escalation, the service continued to have 100% 1:1 care in labour and the labour ward coordinator maintained was supernumerary 100%.

Senior leadership listened to staff feedback on appraisals and appraisal data was shared monthly. The service had an improved appraisal rate for staff, with 90% of staff having had an appraisal. Appraisal data was shared with staff and the service had introduced a new quality improvement model for appraisals to encourage staff have open conversations.

Within the last year the community teams introduced shared learning afternoons for midwives across the trust to network and share learning. The sessions included an hour of ‘speed dating’ where small groups of midwives rotated around different presentations. For example, there were presentations from the police talking about Claire’s law and domestic abuse, to physiotherapists sharing ways women could manage pelvic pain during pregnancy.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service assessed and managed the risk of infection well. This was a significant improvement from our last assessment.

All areas in maternity were visibly clean and had suitable furnishings which were clean and well maintained. Cleaning records were up to date and showed all areas were cleaned regularly and met required standards for the last 3 months. Staff cleaned equipment after contact with women. Staff used ‘I am clean’ stickers to show equipment was clean and ready for use.

Bathrooms and toilets were clean and there were laminated posters explaining the hand washing technique.

Privacy curtains were clean and labelled with their replacement date. We saw housekeepers going about their duties and they were familiar with the unit and cleaning polices. Staff were familiar with cleaning policies for the labour/birthing pools and cleaning records were up-to-date and demonstrated all areas were cleaned regularly.

The service made sure that medicines and treatments were safe and met women’s needs, capacities and preferences. Staff involved women in planning, including when changes happened.

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 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.

The trust used an electronic system to prescribe and record administration of medicines. There were policies and procedures to support the safe and effective use of medicines.

The pharmacy team supported the service and reviewed medicines prescribed. These checks were recorded in the prescription charts we checked. Staff completed medicines records accurately and kept them up to date.