Northampton General 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

This means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question as requires improvement. At this assessment the rating has changed to good. Good: This meant people were safe and protected from avoidable harm.

The service was safe, and birthing women were protected from avoidable harm. Staff demonstrated a strong learning culture. Incidents were reported, investigated, and used to improve practice. Systems and pathways supported safe care and continuity. Multidisciplinary working and escalation processes were effective. Women said they felt safe during labour and birth, and staff responded promptly to changes in condition. Safeguarding was embedded, and risks were identified and managed consistently.

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.

Description: We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

A learning culture was embedded across maternity and community midwifery services. Leaders and staff identified, shared, and embedded good practice.

Incidents were reported and investigated through established governance processes. Poor outcomes were escalated to external investigation teams when required. Staff described an open reporting culture and confirmed learning was shared and informed practice.

Incidents were reviewed through governance meetings, with learning shared across hospital and community teams. Staff described how this improved care. For example, mislabelled blood samples led to immediate changes in practice. Community midwives confirmed this improved safety in antenatal and postnatal care. 3 moderate harm incidents were reported in February 2026, and no incidents had met the threshold for patient safety investigations (PSII) in this month. In terms of perinatal mortality reviews, (these reviews include external panel members) there were no outstanding cases, and all had been reviewed within correct time frames.

Learning was communicated through newsletters, email briefings, weekly maternity updates, and digital platforms. Staff said information was clear and accessible. Actions focused on timely observations, accurate documentation, effective handovers, and prompt escalation. The weekly Maternity Messages feedback from incidents were very impactful and clear.

Leaders shared incidents and near misses without delay. These included delayed observations, incomplete induction documentation, missing transfer notes, safeguarding review delays, and documentation errors. Learning was clear and linked to improvements. Staff said feedback was timely and useful.

An incident involving a monitoring procedure identified inconsistent completion of hourly peer reviews. Learning included correct classification of traces, clear documentation, completion of hourly “fresh eyes” reviews, and timely escalation with time‑stamped records. Effective multidisciplinary emergency response was shared as good practice.

Audit findings from the Neonatal Early Warning Trigger and Track tool identified variation in scoring and documentation. The tool was reviewed and staff received additional training. This supported safer neonatal care and improved compliance with standards.

Governance systems were used to review incidents, risks, complaints, and national investigations. Actions were recorded, monitored, and completed. Leaders tracked timescales and addressed delays. Recurring themes included medicines management, triage pressures, and documentation. These were addressed through quality improvement work and updated guidance. The service had reported 100% of qualifying cases to the Maternity and Newborn Safety Investigations (MNSI) programme and to NHS Resolution's Early Notification (EN) Scheme from 1 December 2024 to 30 November 2025. There had been two such incidents since April 2025. We reviewed three Maternity and Newborn Safety Investigation programme (MNSI) reports and saw robust action plans in place to share and embed learning identified.

Learning from patient safety incidents was shared across teams. Staff discussed themes in handovers, team meetings, and multidisciplinary forums. Themes included medicines safety, documentation, and escalation. Actions were embedded into daily practice and reinforced through training.

Staff used multiple approaches to learning, including governance meetings, ward discussions, multidisciplinary forums, and table‑top exercises. Learning was reinforced during handovers and routine care.

Leaders identified medicines management as a risk linked to documentation errors. A quality improvement programme and working group were established with an action plan to reduce the risk of errors.

We observed structured handovers involving midwifery, consultant, and multidisciplinary teams. Information sharing was clear and risks were communicated effectively. Coordinators used information from previous shifts to plan care.

World Health Organization safety checklists were completed and recorded using electronic and paper systems. Compliance was monitored and supported audit.

The Perinatal Quality Oversight Model (PQOM) was used to monitor safety, quality, workforce, and outcomes. PQOM is an updated NHS England framework for maternity and neonatal services. It provides consistent oversight to proactively identify safety and quality risks before they escalate. Multidisciplinary learning was supported through incident reviews and morbidity and mortality meetings. Learning informed training, clinical practice, and service development. Staff shared learning across sites, including learning from other services to improve documentation, escalation, team working, and digital systems.

Description: We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service had safe, coordinated systems and pathways that supported assessment, risk management, communication, and continuity of care across maternity and community services, including transfers. The newly launched electronic record system was working well. Staff training compliance for January 2026 showed PROMPT training overall was 98% and newborn life support (NBLS/NLS) overall compliance was 97%. The service had achieved the compliance required for PROMPT, fetal monitoring training and NBLS in the reporting period of MIS year 7. This training required 90% attendance of relevant staff groups by the end of the 12-month period at fetal monitoring training, multi-professional maternity emergencies training and neonatal life support training. MIS is the Maternity (Perinatal) Incentive Scheme is a financial incentive program designed to enhance maternity and neonatal safety within NHS Trusts. CTG training compliance was 99% for midwives and 100% for consultants, and 94% for other doctors at the end of December 2025. Cardiotocography (CTG) monitoring tracks a baby's heart rate and womb contractions using external abdominal sensors or an internal scalp electrode to check for signs of fetal distress during pregnancy or labour.

We observed structured multidisciplinary handovers with midwifery, medical, and specialist teams. Handovers were comprehensive, and staff shared risk information. This supported prioritisation and identification of women requiring monitoring. Consultants were present and provided oversight. Records showed the maternity coordinator used previous shift information to plan care, supporting continuity and risk management.

Records showed effective safety systems through checklist reports. Critical checks were completed and recorded for each woman, supporting audit and accountability. The World Health Organization surgical safety checklist was used with electronic and paper records, supporting verification and traceability. We observed consistent use of checklists and theatre whiteboards. Multidisciplinary working was effective.

Clear clinical pathways were in place. Staff understood escalation processes. Governance systems supported oversight, and leaders monitored activity, staffing, and review times. Daily safety huddles reviewed incidents, staffing, and risks. Staff escalated concerns through established pathways.

Triage was located at the entrance of labour ward. The service recognised triage pressures and implemented actions. The triage area included two assessment rooms and a four‑bed observation bay. The Birmingham Symptom Specific Obstetric Triage System (BSOTS) supported assessment and prioritisation. BSOTS ensures birthing individuals are evaluated and treated by urgency rather than order of arrival and ran 24/7.

A telephone triage line supported early advice and escalation. Records and staff feedback identified limited middle‑grade cover after 5pm and weekends, contributing to delays. A plan was in place to address this. Escalation to the on-site consultant was effective. Escalation to labour ward consultant took place in case of emergencies. Phone triage was based in the birthing centre during the day and on labour ward during the night. In February 2026, 75.1% of people were seen within 15 minutes of arrival and 97.2% within 30 minutes. Clear guidance was in place for telephone triage. Triage had a core team of 11 Band 6 midwives, with an additional 8 midwives that were rostered weekly allocation with Triage/Labour Ward. The triage co-ordinator ensured there was a member of the core team on each day/night shift to ensure effective running of triage. Appropriate escalation processes were followed in times of high acuity. All midwifery staff were trained to work in triage. Training resources were robust, this included annual refreshers in BSOTS and were specific to either midwife training or obstetric team (for new doctors). Compliance with training was monitored by means of a training database. Any midwife who worked on the telephone triage line had to also complete annual training.

The labour ward supported safe care, with delivery rooms, observation areas, high dependency beds, and central fetal monitoring. Staff used the ‘fresh eyes’ review system to support decision‑making. Induction pathways were in place; records showed delays linked to staffing pressures. they were mitigating risks of delays to induction and were risk assessing women at least daily. Risks were recorded and reviewed.

The obstetric theatre pathway included two theatres. We observed use of safety systems, including the World Health Organization (WHO) checklist. Staff reported delays with accessing a second team out of hours due to staffing constraints. This risk was recorded. Multidisciplinary working was effective. WHO checklist audits were robust.

Hospital and community services worked effectively together. Staff described coordinated care with partners, including perinatal mental health services. Records and staff feedback confirmed effective handovers, supporting continuity. Community midwives reported confidence in escalating concerns and accessing senior support.

During the organisational transition to University Hospitals Northamptonshire (UHN), leaders reported aligned maternity processes with the other UHN location and improved understanding of possible risks. Staff said work was ongoing.

Systems were in place to identify, monitor, and escalate risks. Daily safety huddles and operational meetings reviewed risks and identified mitigation. The service followed The Family Health Behavioural Framework, which relates to a set of commitments to create a kind, compassionate and honest culture for teams and individuals to thrive in. It is based on 'Communicating Clearly',' Easing Tensions', 'Respectfully Empowering' and 'Proactively Organising'.

For fetal monitoring, central monitoring was in use. Fresh eye reviews were in place. Medical cover was on site with consultants available from 8am-10pm. Audit findings demonstrated that fresh eyes reviews of fetal monitoring were routinely undertaken and documented. Records reviewed showed that staff sought a second opinion when required and escalated concerns appropriately. Areas for improvement were identified in documentation, and actions were implemented to support compliance with local guidance.

A fully electronic record system supported access to real‑time information. Records were clear. Leaders used the system to monitor activity, incidents, and risks, and identify trends, including prescribing and documentation issues. This supported audit and improvement.

Description: We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

We scored the service as 4. The evidence showed an excellent standard. The service always worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They fully concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The service fully shared concerns quickly and appropriately.

The service had appropriate safeguarding systems and support in place to keep women and babies safe. Safeguarding was embedded in daily practice, and staff felt able to raise concerns and received timely support. Effective leadership, supervision, communication and shared learning supported safe decision-making and continuous improvement. All policies were in date.

Safeguarding practice was well embedded and supported by effective working relationships across hospital and community teams. Since July 2025, the safeguarding lead had maintained a visible, accessible and supportive presence across both sites, including Northampton General Hospital. This provided consistent guidance, real-time advice and reassurance, strengthening staff confidence and supporting safe decision-making. From January 2026 data, safeguarding adults Level 1 to 3 training compliance was 91% and safeguarding children's Level 1 to 3 training compliance was 95%.

We spoke with the UHN safeguarding lead and director, as well as staff across maternity services. Staff consistently reported feeling supported by the safeguarding lead and described having reliable access to advice and support when needed across the service. The Named Midwife for Safeguarding UHN now attended the monthly maternity education board.

Community staff described clearer safeguarding processes, improved consistency and accessible escalation routes. They reported better access to safeguarding advice and increased confidence in decision-making.

Staff supported women with complex social and emotional needs, including teenage mothers and those experiencing vulnerability. Care remained compassionate, with appropriate emotional support, including where babies were expected to be separated at birth.

Staff were appropriately trained and demonstrated a clear understanding of safeguarding responsibilities. They recognised concerns, including those related to female genital mutilation (FGM), raised alerts, escalated appropriately and accessed support, including out of hours. Staff knew how to make safeguarding referrals and how to seek advice and support when needed. Reporting processes were clearly displayed, and staff were confident in using them.

Safeguarding supervision was well established and embedded within practice. Staff described supervision, peer review and reflective discussions as accessible and supportive. The safeguarding team provided real-time advice in clinical areas, supporting reflection, shared learning and staff confidence.

Learning was supported through case discussions, scenario-based exercises and team briefings. Staff used these to reflect on practice and apply learning in complex safeguarding situations.

Policies for safeguarding and baby abduction had been updated and were in line with national and local requirements. They outlined clear actions, including escalation and communication procedures. Policies were accessible within clinical areas. Regular infant abduction simulation exercises were conducted to assess staff preparedness and response in the event of a suspected baby abduction.

Training was monitored through governance processes to ensure staff maintained required safeguarding skills. Staff demonstrated understanding of procedures during exercises, including prompt escalation, securing clinical areas and following policy.

Live and tabletop baby abduction exercises had been completed across maternity and neonatal services. Staff understood their roles and responsibilities. Minor improvements were identified, including access to documentation and recording processes, and actions had been taken to address these.

Staff felt supported by the safeguarding team and were able to raise concerns, receiving timely advice and guidance.

Leaders monitored safeguarding activity, themes and data, and reviewed cases to identify learning and improvement. They worked collaboratively with the local authority and health and social care professionals in the community to support effective safeguarding practice.

Description: We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff communicated clearly with women and their partners, ensuring they understood their care, treatment and associated risks at all stages. Women told us they felt well informed during assessment and admission. We observed consultant involvement during sedation on the labour ward, which supported safe and timely decision-making. Staff involved women and families in understanding and managing risk throughout pregnancy, birth and the postnatal period. Community midwives supported women with complex needs to understand their care options and escalation processes, promoting informed choice and continuity of care. Women told us they felt listened to and involved in decisions about their care. Staff responded to individual needs and facilitated appropriate referrals. One woman said, “I have been referred to mental health services and feel supported in getting the help I need.” Feedback from women was shared through maternity governance meetings and used to inform learning and service improvement.

Staff demonstrated a good understanding of women’s emotional needs. Translation services and written materials were available for women with communication needs. Staff encouraged feedback through surveys and direct engagement.

Patient experience staff met with women to gather feedback, which was shared with maternity teams to understand people’s specific needs. The service planned effectively for elective, emergency and triage admissions. Women were assessed on arrival, and triage processes supported timely identification of risk and prioritisation of care. At times activity was high and the service was busy; however, leaders maintained oversight of patient flow, staffing and risk. Staff worked well together to manage demand, and risks were closely monitored. Leaders reviewed capacity and operational pressures to support safe and responsive care. The service prioritised safety through structured handover processes. Information sharing was clear and concise.

Staff took a holistic approach to providing care, encouraging women to express their personal preferences reflective of their cultural background and individual support needs. Care plans were adapted to reflect these needs. Women and their partners said this made them feel respected and involved in their care. Women and their partners described staff as attentive, responsive and confident in recognising when additional support was needed.

Effective systems were in place to capture and respond to patient experience. Feedback from surveys and direct engagement was shared with staff and used to inform improvements. Changes included enhancements to facilities and enabling partners to stay overnight. Women reported these changes improved their experience.

Description: We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

We scored the service as 3. The evidence showed a good standard. The service 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 processes in place to maintain a safe environment, despite the challenges presented by the aged estate. Staff carried out regular environmental checks across all maternity areas. Clinical areas, including delivery rooms, the birth pool room, triage rooms, clean utility rooms and observation areas, were clean, tidy and well organised. Toilets were clean and well stocked. The environment supported holistic care, including access to a birthing pool room designed to promote a calm and relaxing atmosphere. One woman told us, “I am glad I chose the birthing pool and would definitely use it again.” Birthing centre was on the 1st floor, and homebirths were supported whenever possible.

Stock was within expiry dates, and equipment displayed current maintenance stickers. Staff completed daily checks of resuscitation equipment. The resuscitation trolley showed consistent compliance, with intact seals and clear records of daily checks. Medicines were stored securely. The contents of drug emergency and resuscitaires were neat and tidy with checking logs all verified as in date and the contents all within expired dates.

Drug cupboards were locked, controlled drugs registers were up to date, and gases, fluids and consumables were stored safely. Fridge temperature monitoring, electrical safety testing and daily equipment checks were completed as required. Despite operational pressures, staff maintained a strong focus on safety. Monthly fire safety audits were robust.

A structured approach to environmental checks was in place, supported by strengthened governance arrangements. We reviewed the trust’s fire drill inspection checklist and monthly environmental audits. These showed improved compliance across maternity services and reflected sustained attention to safety and cleanliness standards.

The service had a detailed emergency evacuation plan in place. Governance systems showed that processes were in place and operating as intended. Risks were identified, monitored and escalated appropriately, with action taken where compliance was lower.

Governance processes supported a continued focus on infection prevention and control, with facilities and IPC teams working together to identify and address environmental risks. Information boards, including QR codes and multilingual signage, were visible throughout the unit. Data showed improved compliance with planned preventative maintenance (PPM) for all equipment, including high-risk devices, between September 2025 and February 2026. This provided assurance that equipment was serviced and maintained in line with safety standards. Mattress audits identified no concerns and showed that equipment used to support clinical care was clean, fit for purpose and appropriately maintained.

However, staff reported challenges associated with the ageing estate. These included limitations in room layout, storage capacity and the condition of some clinical areas. The environment and estate risks were recorded on the service risk register, with associated actions and plans in place to address them.

Some areas were part of an older build and did not fully meet the needs of a modern maternity service. Senior leaders recognised the environmental challenges and had begun taking action to improve the environment. This included recent redecoration of rooms within the birthing unit to improve the experience for women and their families. We spoke with the leadership team, who confirmed that plans were in place to address environmental concerns. Staff told us that leaders were accessible and understood the environmental challenges.

Infection prevention and control (IPC) and facilities teams worked collaboratively to maintain safety and prioritise improvements. Developments, including upgrades to staff areas, were subject to business case approval, which was in progress and identified as a priority. Changes had been made as a result of approved business cases, and local teams had implemented improvements to equipment to support safe care. Longer-term plans were also in place to increase space and improve the environment.

The high dependency area continued to experience pressure due to estate constraints, patient flow and staffing challenges. Staff used clear escalation processes, regular monitoring and structured communication to maintain safety.

Feedback from people using maternity services highlighted concerns about the environment. Facilities and IPC teams worked closely together, using audit findings to prioritise and address estate-related risks and support ongoing improvements. To ensure ongoing oversight, the IPC and Estates teams planned to carry out a quarterly review of the Maternity Services estate throughout 2026/27. This would be undertaken jointly with the Maternity Matron responsible for IPC within the service. The aim of this programme was to maintain high environmental standards and ensure any emerging issues were promptly addressed. During the inspection, we highlighted some minor décor issues, which the trust promptly rectified.

Description: We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

We scored the service as 3. The evidence showed a good standard. 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 demonstrated sustained improvement in midwifery staffing, supported by a comprehensive, evidence-based workforce strategy. Although staffing pressures were identified in some areas, the trust had embedded robust workforce planning processes underpinned by the Birthrate Plus national midwifery workforce planning tool and the systematic use of monthly acuity and dependency data. Staffing levels were calculated on clinical need and historical data needed to achieve the best outcomes for women. The service demonstrated an effective system of clinical workforce planning to the required standard. For February 2026, UHN maintained stable Operational Pressures Escalation Levels (OPEL) levels, with NGH remaining at OPEL 1. OPEL is a national framework used to measure and manage the level of stress, demand, and busyness a hospital, mental health service, or health system is experiencing at any given time. An OPEL level 1 meant the system was operating normally, demand was met safely within available resources, and no special actions were needed

Red flag events were recorded, mostly linked to delayed or cancelled critical activity, but without triggering service disruption.

Senior midwives had strengthened internal capability through completion of the NHS England Chief Nursing Officer Safe Staffing Fellowship. The trust had taken a proactive and forward-looking approach to managing workforce pressures, using modelling and scenario forecasting to anticipate future demand and mitigate risk. Staffing arrangements supported the delivery of safe care across both maternity and community services. Community midwives described clear caseload allocation, continuity of care, and consistent access to senior support. Across maternity services, staff described daily review of staffing levels, with visible and responsive senior oversight, particularly during periods of increased activity. The Trust continued to review and strengthen workforce planning as part of wider organisational changes.

Between April 2023 and February 2026, the midwifery workforce increased from 144.10 WTE to 188.45 WTE. This growth had been achieved through international recruitment, improved retention, enhanced preceptorship, and expansion of the newly qualified midwife pipeline. A temporary increase in vacancies during 2025 and 2026 reflected the planned conversion of Maternity Support Worker roles into registered midwifery posts. Staff said it felt as though vacancies were higher than they were due to sickness absence and maternity leave; however, these pressures were actively managed through rota matrix reviews, strengthened roster oversight, and improved annual leave planning. Workforce modelling indicated that the service was progressing towards near full establishment by late 2026. Retention of student midwives was 100% with 24 of the 25 international trained midwives recruited for 18 months all securing permanent posts and 1 person deciding to return home. Minimum safe staffing levels (labour ward only) were met 86% of the time in February 2026.

The service had 91 maternity support workers. The maternity support worker programme was launched in 2023 to comply with the National Framework Maternity for support workers. New starters joined as maternity care assistants and attended a four-week induction with a competency passport to be completed withing the first 10 to 12 months. On completion, they attended neonatal training and additional training, and they were awarded their maternity support worker award/badge.

Leadership capacity had been strengthened through the appointment of a Deputy Head of Midwifery, a cross-site Workforce and Culture Matron, expansion of Band 7 labour ward coordinator roles, and continuous senior midwifery on-call cover. This provided consistent senior leadership, strengthened operational oversight, and improved staff support. Skill mix was optimised through effective deployment of Maternity Support Workers, integration of Registered General Nurses within postnatal pathways, and twice-weekly cross-site roster review meetings. Redesign of key pathways, including induction of labour and elective caesarean sections, had reduced operational pressures and improved flow. The implementation of electronic maternity records in November 2025 further enhanced visibility of staffing levels, acuity, and clinical activity in real time.

Governance and leadership arrangements provided clear oversight of staffing at Board level. Regular reports included fill rates, vacancy levels, workforce risks, and mitigation actions. There was clear alignment with National Quality Board safe staffing principles, supported by a well-established safe staffing policy which underpinned consistent and transparent decision-making.

Governance processes were well embedded. One-to-one care in labour was maintained in almost all months reviewed. Escalation episodes were infrequent, well-managed, and appropriately documented. Clinical outcomes remained stable, with no evidence of deterioration linked to staffing pressures. Key indicators, including preterm birth rates, breastfeeding initiation, stillbirth rates, and neonatal outcomes, showed no adverse trends.

Leaders demonstrated a clear understanding of the importance of maintaining one-to-one care in labour as a fundamental standard. Regular monitoring and audit processes were in place, and findings were shared across teams to support continuous improvement and consistency in practice.

The latest Birthrate Plus assessment in August 2023 confirmed that the funded establishment aligned with national recommendations. Preparation was underway for the next assessment scheduled for summer 2026. Monthly acuity assessments informed real-time staffing decisions and supported early identification of pressure points. Two senior midwives were undertaking a national leadership fellowship to further strengthen workforce planning expertise.

Recruitment and retention were supported by structured pastoral care, improved induction, and a strong preceptorship model. Internationally recruited midwives demonstrated good retention, and recruitment activity continued throughout 2026. Externally funded roles, including preceptorship and recruitment support posts, were being transferred into substantive positions. Vacancy projections showed continued improvement, with the service expected to reach near full establishment by early 2027. Focus continued on induction of labour pathways, which generated most red flags for staffing. Midwifery Red Flag events were primarily linked to delays in time-critical activity, most commonly due to ongoing delays in Artificial Rupture of Membranes (ARM).

The midwifery led unit had had no closures in the period April 2025 to February 2026.The midwife to birth ration in February 2026 was 01.22 (annualised delivery rate) and 1:1 care in labour was achieved 100% in February 2026.

Leadership and governance teams had developed a clear methodology to strengthen recruitment, retention, and workforce structure, with a strong focus on staff wellbeing. This included targeted recruitment campaigns, enhanced pastoral support, flexible working arrangements, and professional development opportunities. These approaches recognised the clear relationship between workforce stability, staff experience, and the delivery of safe, high-quality care.

Training compliance remained high, with midwives, obstetricians and anaesthetists exceeding 95% compliance. Training compliance with PROMPT, Newborn Life Support, and fetal monitoring were all above 95%. PROMPT (PRactical obstetric Multi-Professional Training) is an evidence based multi-professional training package for obstetric emergencies. It is associated with direct improvements in clinical outcomes through improvement in knowledge, clinical skills, and human factors.

Leaders ensured staff received training in diabetes care in pregnancy. Staff understood pathways, recognised risk and provided safe care.

Medical staffing cover met people’s needs. There were no consultant obstetrician or neonatologist vacancies. Consultant staffing at time of the inspection was 11.9 whole time equivalent (WTE) in post with 8.9 WTE able to undertake full clinical duties and 2 WTE off long term sick leave. The service was supported by 2 agency locum consultants. Middle grade staffing was 8 WTE Trust doctors, 7 WTE middle grade trainees, 10.3 WTE Specialty Trainee doctors and 6 WTE Foundation Year 1 doctors. This staffing allowed 2 middle-grade doctors at all times. There was a consultants’ team of 10 on call with designated time for educational supervision. A training week was built into the rota to cover all staff. The service did not work on a consultant of the week model, but a pair of consultants had a fixed day. The elective caesarean list was covered by a separate team. Consultants’ job plans included a good balance of clinical and developmental time. The labour ward had anaesthetic registrar cover 24/7 and a consultant until 6pm on site and then from home. Medical cover for triage was being reviewed.

The Year 7 MIS audit of consultant attendance on the labour ward, covering the period 1 June to 31 August 2025 provided strong assurance that consultant involvement aligned with RCOG guidance and supported patient safety. Of 169 cases meeting RCOG-defined escalation criteria, 98% demonstrated either direct consultant attendance or management by a senior doctor formally signed off as competent.

The RCOG “Team of the Shift” process was firmly embedded within Labour Ward handovers. At each handover, all members of the multidisciplinary team – including resident doctors – formally introduced themselves. This enabled real-time situational awareness and provided consultants with clear oversight of resident doctor staffing, allocation and wellbeing on the Labour Ward. If a resident doctor was unable to attend their shift due to sickness or other absence, they were required to notify the consultant on call by telephone. A clear escalation process was in place to ensure that Labour Ward resident doctor cover was prioritised at all times. This included access to resident doctor rota coordinators, comprising an administrator, a consultant and a resident doctor, supported by Band 7 managers to ensure timely mitigation of any staffing gaps.

Resident doctors completed a QR-code-linked electronic form to confirm consultant attendance at all “must” and “should” occasions in line with RCOG guidance. A formal sign-in at Labour Ward handover, this QR code form had been enhanced to explicitly include the surnames of all resident doctors on shift, alongside consultant names.

Description: We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff and leaders demonstrated a proactive and systematic approach to infection prevention and control (IPC). The service had an up-to-date IPC policy in place and staff-maintained equipment to a high standard, ensuring it was consistently clean, labelled with in-date “I am clean” stickers and cleaned between each use. Clinical areas were visibly clean, well-organised and appropriately furnished, supported by dedicated domestic staff. Cleaning records were complete, up to date and showed several areas achieving five-star cleanliness ratings.

The service operated within an ageing building, which presented ongoing environmental limitations, including restricted space, limited storage and a constrained layout. These factors increased the risk of infection however leaders recognised this, had recorded hazards on the risk register and were working with the IPC and estates teams to mitigate impact. Improvements were ongoing, including refurbishment within the birthing unit to support better use of space. Staff used available areas effectively, including family rooms and the birthing pool room, and reported this had not impacted their ability to maintain IPC standards.

Staff followed IPC principles, including effective hand hygiene and appropriate use of personal protective equipment (PPE). audit data showed 100% compliance for hand hygiene and correct PPE usage. However, there was variation in wider IPC compliance. Fit testing for FFP3 masks was 50% on the labour ward and 85% in other areas, Mandatory IPC training compliance remained below the trust target of 85% at the time of the inspection. Leaders recognised these risks and had taken action, including dedicated fit-testing sessions, strengthened reporting arrangements and actions to improve training uptake. Audits seen showed that the service performed very well on checks by the trust’s IPC team. Hand hygiene and PPE audits in January to March 2026 showed 100% compliance in all areas. Overall, IPC governance arrangements provided assurance that risks were identified, managed and escalated appropriately.

There was a designated IPC lead, and structured quarterly walk-arounds involving maternity, IPC and estates teams. These were to support the early identification and prioritisation of environmental, equipment and cleanliness risks. Actions were logged and progress monitored Systems for replenishment, replacement and repair had improved, increasing equipment reliability. This supported timely repairs and clear communication with the estates team.

Staff awareness of IPC requirements was supported through regular communication, including an IPC bulletin and a trust-wide sharps safety initiative. These reinforced safe practice and improved understanding of risk. We spoke with senior leaders who described ongoing improvement work, including reinforced IPC reminders, increased focus through local team meetings and strengthened oversight of compliance. Leaders demonstrated awareness of environmental limitations and had plans in place to address these and improve overall assurance of IPC standards.

Description: We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

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

Staff followed national guidance for medicines management, including safe storage, prescribing, administration, recording and disposal. Medicines were used safely to support women and birthing people throughout their care, including providing pain relief in labour, supporting labour when needed, preventing complications, and aiding recovery after birth. Newborns received medicines in line with national recommendations to keep them safe and well.

Medicines reconciliation was completed from initial assessment through to admission to support safe care. Staff understood how to use medicines safely and followed local policies and procedures. Systems were in place to monitor the effectiveness of medicines and respond to concerns.

Women were offered pain relief during labour and given clear information about their options, enabling informed choice. Staff were responsive and regularly reviewed women’s comfort. Women said they felt listened to, involved in decisions, and received pain relief when needed.

Medicines were stored securely and checked regularly to ensure they were safe to use. Emergency medicines and equipment were available, checked, and ready for use. Staff understood how to respond to deteriorating women and babies.

Between October and December 2025, 22 medicines management incidents were reported. Incidents were reviewed to identify themes, including administration, prescribing, stock control and documentation. Monthly pharmacy audits identified areas for improvement. Audit activity had become more consistent, and learning from incidents and audits was used to improve practice. Information was shared with staff through team discussions and learning summaries. A multidisciplinary medication management working group had been established and was developing a new action plan to drive improvement.

Actions were implemented to improve safety, including new checklists for medicines storage and controlled drugs, clearer responsibilities for staff in charge, and regular auditing. Action plans were developed, reviewed, and shared across the multidisciplinary team, including midwifery, obstetric, neonatal and pharmacy staff.

Women felt supported and reassured, were involved in decisions, received clear explanations about medicines, gave consent before treatment, and had access to written information to support understanding.

We noted the immediate action taken by the trust in response to a potential risk issue that we raised. (Some fetal blood sample boxes were out of date, but were not in use, so no risk apparent.)