St James's University 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question Requires Improvement. At this inspection the key question rating went down and we rated the key question as Inadequate. This meant people were not safe and were at risk of avoidable harm. The service was in breach of the legal regulation relating to incident investigation and management, risk management, staffing, safe environment, infection prevention and control and medicines management. We also issued the service with a warning notice in regard to staffing.

The service did not always have a culture of safety and learning. *Safety and continuity of care was not always a priority throughout women’s care journey. Investigation and learning were not always evident following incidents, and we saw women experience further delays and omissions of care, as a consequence of this. There was an awareness of the risks to women across their care journeys. However, records indicating how risk was measured, were not always completed. The service demonstrated some improvements with the triage systems and staff communicated well to ensure women’s needs were prioritised.

Medicines were not always stored or administered safely in maternity theatres.

The service did not always have enough staff for the number and acuity of patients and staffing shortages impacted the quality of care and treatment provided. Prior to and during the inspection we received concerns from staff and women regarding low staffing numbers and we were able to corroborate this with our onsite findings. We were therefore not assured that safety was a top priority for the service and we issued a warning notice, which required the provider to take immediate action.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always 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 looked at 10 incidents logged using the Trust’s electronic incident reporting system as part of this inspection. Leaders told us that incidents were reviewed against PSIRF (Patient safety incident response framework) guidance, with decisions about further investigation made at a local level. We also looked at patient safety incidents and found that although they had action logs, these lacked detail including timescales and those responsible for actions.

All the staff we spoke with told us they were aware of how to report incidents, but some staff told us incidents were not always reported because they did not have time to complete incident reports online, prioritising care of patients instead.

We asked staff if they could describe an incident where lessons learned had been shared. Some staff could not recall any examples of shared learning and others told us about incidents that they had reported but where no learning or outcomes were shared back to them. Staff were not confident that action had been taken because of the incidents they had reported. During and after the inspection, staff contacted CQC to inform us of examples when similar incidents had reoccurred. Therefore, we were concerned that lessons were not always learned or were not effectively shared with staff.

Risk meetings were in place to discuss any incident reports that identified moderate harm or above. However, staff told us these had become inconsistent, and it had become difficult for them to plan to attend due to being required to cover shifts and gaps in rosters.

Staff told us that ward managers often worked clinically on the wards and therefore, some tasks were not able to be completed such as attendance at risk meetings where learning from incidents would be discussed. We additionally identified that incidents appeared to be looked at in isolation and there was a lack of documented analysis to identify themes and trends or proactively work to prevent future incidents.

Staff contacted us during and after the inspection to tell us of specific incidents which they felt either could have been prevented with learning from previous incidents, or incidents which they believed had not been thoroughly investigated with lessons learned identified to prevent future incidents.

The service provided minutes of the PMRT review process, however, the minutes did not include those who attended the meetings. This meant we could not be assured the reviews were carried out in line with best practice guidance with all the health care professions involved with the woman's care. We were also not assured that parents and families were involved. Further, the patient safety response plan does not detail how families will be included in investigations.

Following the inspection, the Trust provided us with attendee lists which were kept separately from the meeting minutes. The Trust also informed us that the attendees are now incorporated into the minutes as per best practice.

We reviewed the latest CQC Maternity Survey results from 2024 and saw the Trust performed ‘About the same’ as other organisations in relation to involvement in decisions, opportunity to ask questions, and information and explanations after birth.

The care, treatment and support people received was mostly planned in collaboration with patients, their families, health care partners and care providers. It was done in a way that maximised continuity of care throughout the person’s care pathway as much as possible however it was not always a priority. Vulnerable and high-risk patients were supported by community midwives who built relationships with people over time, building trusted links within communities. Staff told us the number of lower risk pregnancies had decreased over time and that an increasing number of women had higher risk pregnancies due to health conditions and lifestyle choices. Patients who were identified as having an elevated risk pregnancy had risk assessments carried out and care plans put in place. These were completed with people and were in place to ensure people received treatment and care in line with national guidelines throughout their maternal pathway.

The Trust had an electronic repository of policies, procedures, patient pathways and guidelines, both local and national. This was called Leeds Health Pathways and was accessible to clinical staff. During the inspection we saw staff accessing the system.

Staff carried out foetal wellbeing monitoring using a process called cardiotocography (CTG) and the Trust had a central monitoring process which enabled senior and more experienced midwives and obstetricians to continually monitor the condition of women and identify and escalate any signs of deterioration or difficulty in a timely way.

Due to the staffing and bed pressures and the high volume of patients attending the hospital, twice daily bed meetings took place. Although staff tried to place patients in the most appropriate setting, this was not always possible and there were times when patients did not receive the care and support, they needed. There were times when patients were at risk of not receiving the most appropriate care and support to meet their individual needs. For example, we heard that women with previous experience of miscarriage were placed on the post-natal ward overnight for antenatal care provision. This could be distressing for some women.

The service worked with people to understand what being safe means to them as well as with their partners on the best way to achieve this. They concentrated on improving people's lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and they made sure they shared concerns quickly and appropriately.

Staff understood how to protect women from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.

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Staff received training specific to their role on how to recognise and report abuse. Staff we spoke with had completed online safeguarding training in the past year. The Trust provided data that as of 19 December 2024 medical and midwifery staff had completed safeguarding adults and children level 3 training against the Trust target of 80%, with the exception of the antenatal ward which was 79%.

There was also an easily accessible and up to date safeguarding policy in place. This provided staff with guidance about actions to take when they had safeguarding concerns about people. The Trust had a separate electronic record for maternity and neonatal services. Both were used for the recording of safeguarding flags and alerts. However, maternity, and neonatal services also used a second electronic recording system that required an upload of safeguarding flags and alerts. There was a risk that information could be missed if both systems were not updated. Midwives were alert for potential safeguarding concerns at each contact with women. This included questions about domestic violence. However, when we reviewed records of when things had gone wrong, this showed that staff did not always discuss domestic violence with patients.

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Midwives referred to specialist teams if safeguarding concerns were identified. There was a specialist team to support teenage pregnancies. The `Haamla' team supported women and their families from ethnic minority communities including asylum seekers and refugees. Women were given options to be seen at home, in the community or in hospital.

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Staff knew how to make a safeguarding referral and who to inform if they had concerns. Staff could access the safeguarding team which was made up of safeguarding specialist midwives and perinatal mental health midwives who oversaw the care of vulnerable women having babies at St James's University Hospital.

Safeguarding specialist midwives attended multi-disciplinary meetings with lead agencies (the local authority) to discuss current safeguarding concerns and policy updates.

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Staff received some safeguarding supervision. In community midwifery services this was in the form of peer support and there were safeguarding champions across maternity services who staff could contact for support and advice. Advice was recorded on the electronic record keeping system used by the Trust.

Staff told us they followed the baby abduction policy and undertook baby abduction drills. They were mindful of the need to be vigilant regarding entry and exit to ward/unit areas. All access and exit points were monitored by security phone cameras. We observed staff undertaking security checks with visitors attending wards/units.

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At the last inspection in May/June 2023 the service was in the process of having a `baby tagging' system installed on labour and postnatal wards in order to improve the risk management of baby abduction. At this inspection the baby tagging system was in use, since November 2023. All wards that care for neonates were fitted with swipe card access to facilitate monitored and authorized entry and exit to the area.

The rationale for the application of the tag was offered to all parents to facilitate informed choice of whether they wished their baby to be tagged. The offer was not accepted by all parents. Staff informed us some parents had expressed concerns regarding minor abrasion and reddening to baby's skin where the tag was fitted. The Trust later informed us that this was being addressed through training.

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This was discussed on the labour suite post-delivery; however, tags were routinely fitted on post-natal wards. We observed monitors on the wards/units which identified babies who had been fitted with the tagging system. The monitor alarmed if a baby is taken from the ward/unit. The alarm had to be physically silenced by staff following immediate safety checks of the baby.

The service had a policy/procedure in place for the safeguarding of a missing or abducted child. The policy was dated April 2024 and had a review date in place of April 2026. We saw evidence that the service had instigated a baby abduction drill in August 2024. The drill was facilitated, there was a debrief with staff with learning points and actions for improvement. Actions from the abduction drill was through the sub speciality forum and women's quality assurance group. The service told us they planned regular abduction drills throughout the year in different departments of the service however we found that only one had taken place in the previous 12 months and improvements identified during the drill had not been completed by the time of our inspection.

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The service did not always work with people to understand and manage risks by thinking holistically so that care met their needs in a way that was safe and supportive and enabled them to do the things that matter to them. However, feedback was generally positive with women stating they felt involved in decision making and advice. We also reviewed the national maternity services survey which corroborated this.

Senior staff informed us that daily safety huddles incorporated discussions about the potential risks of birthing women. Twice daily bed management and flow meetings were also carried out to address ongoing service pressures.

The service had developed dashboards to show service key performance indicator compliance. We reviewed the September 2024 dashboard and saw the Trust monitored a number of KPIs including but were not limited to premature births, still births, post-partum haemorrhage, and tear rates. Actions to be taken were shown against each area requiring improvement. However, there was no recorded accountability against each action and no timescales in which to undertake them.

We also reviewed Newborn early warning track and trace audit dated January 2025 and saw that neonatal observations were carried out, however compliance with frequency and duration was suboptimal.

The service had also made improvements to the telephone triage assessment process, including the monitoring of repeated and drop calls. Overall, this system had improved the compliance of triaging women within 15 mins. A clinical audit carried out in December 2024 showed that patients categorised as priority 2 however, waited on average 45 minutes and 25% of priority 3 and 4 cases were not seen within their category time frames. A cross-site piece of work had been carried out and demonstrated improvements.

However, the senior midwife managing triage was also involved in some clinical ward-based activity, which at times created additional operational pressure. This improvement was made following feedback from our previous inspection.

Both the midwife assigned to triage calls and the Ward Manager were sometimes involved in clinical activities, in line with their roles and responsibilities. During periods of high acuity this meant that the ward manager was not able to fulfil all managerial duties such as attending daily safe staffing meetings.

We observed the labour ward coordinator who had oversight of the service flow and overall pressures across the maternity wards. All wards and departments we visited were exceptionally busy. We saw that the coordinator was contacted constantly due to operational pressures in the system and on the SJUH site. This was a concern because this key member of staff no longer had an overview of the system pressures. We were concerned because this may impact their ability to make crucial decisions about care without interruption or distraction. This is not in line with Birmingham symptom specific obstetric triage system (BSOTS) guidance, and we brought this to the attention of senior leaders of the service during our inspection.

At our last inspection we identified concerns regarding the management of women in the waiting area within the maternity assessment clinic, some of whom were waiting more than 4 hours. We identified that there was no clear line of sight of those in the waiting area with little information regarding how to seek help if needed.

At this inspection we noted staff had the ability to observe women waiting in the triage area. We saw that windows had been put into the doors separating the clinical area and the waiting area. This was an improvement, however, the windows did not provide full line of sight into the waiting area because some seats were still not visible.

We were also told that buzzers had been made available for people sitting in the waiting area. We asked three people at different times if they had been provided with buzzers or knew how to seek help whilst waiting. None had been provided with nor offered a buzzer and were not able to clearly identify their position in the care pathway since arriving at the unit. Both days of the inspection women waiting in this area did not have access to portable buzzers, the MAC was busy, and staff did not have regular opportunity to have direct line of site into the waiting area.

During the inspection we saw women could reach call bells in most ward areas. However, feedback from women and their families at the time and following our inspection indicated ongoing issues with staff not always responding to call bells in a timely manner on the postnatal ward.

This was an ongoing risk as women in this area required ongoing monitoring. There was no water or toilet facilities immediately available to women in this waiting area.

The service did not always have enough suitable equipment to help them to safely care for women and their babies. For example, during inspection, both the maternity triage assessment unit and the antenatal day unit did not have enough cardiotocography (CTG) machines equipped with Dawes Redman analysis available to assess women. CTG is widely used in pregnancy as a method of assessing foetal well‐being. CTG monitors equipped with Dawes Redman analysis are used before birth (antenatally) to monitor the baby’s well-being.

Both units had 1 machine each. Staff informed us some CTG machines were broken which required repair. The machines had been reported and were with the medical physics team awaiting review and repair. Staff informed us the units shared available machines at times of high acuity and demand. Staff told us if no CTG machines were available, they completed auscultation of the baby every 30 minutes and repeat observations of the women’s blood pressure and heart rate. This was a risk as intermittent auscultation is recommended for low-risk pregnancy; however, the health of a foetus is assessed using not only the rate but the variability over time, best practice is to use machines equipped with the Dawes Redman analysis. Therefore, staff were unable to effectively assess women requiring foetal well‐being monitoring.

We escalated this to senior leaders who told us the service had 7 CTG machines in total. They agreed to review the lack of available machines. There was no log to evidence what each department had in terms of in action / out of action and when they get moved across to delivery/antenatal clinic which also can happen. Additionally, the lack of CTG monitors was not recorded on the services risk register.

Staff told us if no CGT machines were available, they completed auscultation of the baby every 30 minutes and repeat observations of the women’s blood pressure and heart rate. This was a risk as women with reduced foetal movements required monitoring of the baby to monitor the baby's heart rate. At the same time, it also monitors contractions in the womb (uterus). CTG is used both before birth (antenatally) and during labour, to monitor the baby for signs of distress.

There was no dedicated space for midwives taking triage calls within the maternity assessment centre. Due to the layout of the unit there was a risk that other women within the clinical area could hear calls being taken meaning confidentiality was compromised. There was also a risk that taking calls within a busy environment could mean information was missed.

Since the last inspection the labour unit had refurbished the Snowdrop bereavement suite. Mothers who experienced pregnancy loss were given options to use the bereavement suite. The labour unit also had an additional room called the bluebell suite which had on suite bathroom facilities.

Staff carried out daily safety checks of specialist equipment. Staff used an electronic system to check emergency equipment. This system showed few exceptions for checking equipment and where gaps were identified, these were escalated to ward managers for follow up.

The service kept an equipment register, which showed all medical devices were in date for servicing.

Clinical waste was not always stored correctly or securely. Sluice rooms were freely accessible to inspectors and the public, creating a risk of biohazard transfer and access to chemicals. Service leaders told us that lockable cupboards were to be ordered to rectify this because of our inspection.

The service did not always detect and control potential risks in the care environment.

The service had two maternity theatres located on the delivery suite and three enhanced maternal care beds for women requiring a higher level of monitoring after delivery.

These areas had the necessary equipment to keep people safe.

During our inspection we looked at the maintenance and servicing records of equipment and found that this was up to date. Equipment had undergone safety testing and maintenance in line with requirements. Equipment was stored securely however some corridors were not clear of obstructions. We brought this to the attention of managers who told us these areas would be cleared and tidied.

We found temperature checks had been taken for fridges storing medicines and baby milk. This made sure they were stored at their optimum temperature keeping them safe for use and maintaining their effectiveness.

The maternity unit access was fully secure. There was a monitored buzzer entry system to the labour unit, antenatal ward, maternity triage assessment unit and the post-natal ward and optional baby tagging.

The service could not always make sure there were 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.

Medical staffing

We received a number of anonymous concerns from staff regarding medical and midwifery staffing shortages. Staff were concerned this posed a risk to mothers due to the potential of leaving minimal cover and ongoing medical oversight at times of high acuity and demand. We noted some gaps in rotas were highlighted on day and night rotas. We escalated this with senior leaders at the time of the inspection. Junior medical staff had also raised concerns to the clinical director about this through their forum requesting assurance about short notice sickness cover.

The Clinical Support Unit Clinical Director was responsible for medical staffing of the service. There were established processes within the escalation document for medical staff deployment. This was coordinated collaboratively with the business/service managers, the Workforce Lead Consultant and the lead clinician, including offering enhanced pay rates for covering shifts at short notice. However, CQC were not assured that there was sufficient medical cover to always keep patients safe. This was because there continued to be gaps in rotas and times when medical staffing was insufficient to meet patient needs. We also saw an example that demonstrated that the escalation process did not work effectively because escalation had not been carried out in line with process. This left gaps in the rota, increasing the risks to patients.

Junior medical staff told us there was no protected time for learning or induction when they were new in post. This posed a risk to women, as medical staff may not have completed the required learning prior to undertaking clinical duties. We requested formal mandatory training rates from the provider and saw mandatory training completion compliance figures were below the Trust’s own target of 80%.

For example, adult resuscitation compliance was 73%, equality, diversity and human rights compliance was 67%, patient safety compliance was 60%, safer blood transfusion compliance was 62%, venous thromboembolism compliance was 67% and PREVENT training compliance was 62%.

Midwifery staff told us that medical cover was mostly sufficient, however the antenatal unit had no dedicated medical cover. Staff told us this resulted in delays for women waiting for medical review, assessment, treatment, and certain prescriptions. One midwife described regular delays with mothers experiencing reduced fetal movement.

We reviewed Birmingham Systems Specific Obstetric Triage System (BSOTs) audit data submitted by the service dated December 2024, but we were not assured that reviews carried out by doctors were audited, as they were not included.

Nursing staff told us a new system had recently been introduced in which concerns could be escalated to team leaders. Team leaders were supported by an onsite matron and decisions could be made to move women to appropriate wards when required.

There was no 24-hour resident consultant cover at this location. Consultants on call were expected to be able to reach the hospital within 30 minutes of being called. However, we saw incident reports which reported delays in consultants attending when called. When we spoke with junior doctors at focus groups, they told us they mostly felt supported by the majority of senior clinicians who often worked beyond 10pm to make sure the department was in a stable situation before leaving. Consultant job plans reflected this.

Midwifery and support staffing

There was not always sufficient suitably qualified and experienced midwifery and support staff deployed to keep patients safe. This corroborated the anonymous concerns raised to us.

As part of this inspection, we visited the day unit, ante natal ward, labour ward, post-natal ward, triage area and theatres. We saw staff working hard to manage the care, treatment and support of women. However, it was not always possible for them to do this in a timely manner or take as much time as they would have liked to with patients.

The service reported maternity red flag incidents in line with the national institute of healthcare excellence (NICE Guideline 4 'safe midwifery staffing for maternity settings). A midwifery red-flag event is a sign that something may be wrong with midwifery staffing. Between May and September 2024, the service provided evidence which showed they had reported 170 maternity red flag incidents. We saw that 52% (n89) were delayed time critical activities and 41% (n70) were delays between admission for induction of labour and the beginning of the process of more than 2 hours. However, the data does show that during the same time frame the service reported that all women had 1:1 care in established labour, and the labour ward coordinator was able to maintain supernumerary states at all times.

Between April 2024 and November 2024 St James’s University Hospital submitted 19 Red Ward forms. Red ward forms are submitted when the ward staffing drops below safe staffing levels or available workforce does not meet acuity. The Red Ward forms detail the shortfalls in care and any mitigations as there is an increased risk of harm occurring.

Midwives mostly worked on a rotational basis, working 6 months in a team before moving to another area of maternity services. There were, however, some senior midwives who remained in place on units to offer stability and experience. Rotating staff meant ensuring all midwives maintained their skills and competencies within the entirety of the maternity journey.

During and following the inspection we received a number of concerns from midwifery staff regarding midwifery and midwifery support worker staffing shortages. Staff told us shortfalls impacted on staff having the time to always provide safe care and treatment consistently. Staff told us that staffing levels meant they could provide necessary treatment, but not the quality of care they wanted to provide. They were also concerned about staff dealing with situations outside of their experience and capability due to the shortage of senior midwives. Additionally, staff told us they would often forgo meal and comfort breaks to ensure women remained as safe as possible.

We saw planned and actual staffing numbers were displayed on every ward. There was a safe staffing and escalation protocol to follow should staffing levels per shift fall below the agreed roster. The service used ‘safecare’ professional judgement tools as an additional function of the roster system to determine real time assessment of patient acuity and therefore the staffing required. A rag rating was given in accordance with the department needs and discussed in the daily staffing meeting. We observed this staffing meeting and saw no additional information was considered such as dashboard data, when deciding clinical priorities.

We held staff focus groups following the inspection. Staff told us they felt overlooked and that senior leaders did not always listen to their concerns regarding staffing shortages and the impact this had on moral and wellbeing. Staff informed us they did not always have time to take breaks due to clinical numbers, acuity and lack of staff to support this. Staff also informed us that band 7 midwifery staff who were rostered as clinical coordinators did not always have time to undertake non clinical duties. Due to staffing shortages, they were often required to work clinically. This impacted senior staff not always having availability to complete non clinical tasks for example staff rostering, clinical audit, oversight of risk management, and attending lessons learned meetings.

Women provided feedback which clarified how the shortage of staff impacted on their pregnancy pathway which included antenatal, delivery and post-natal care. They informed us staff shortages impacted on timeliness of pain relief, answering call bells in a timely way, having to wait for catheters to be removed post C-section and lack of support with breastfeeding as staff simply did not have the time to always support this.

At the time of our inspection, there were 9 whole time equivalent (WTE) midwife vacancies in the community midwife team and 4 WTE midwifery support worker (MSW) vacancies. In addition, there were vacancies at band 5 and band 6 across maternity services in the Trust. Due to midwives being rotational, vacancies were Trust wide.

The Trust was actively recruiting midwives and midwifery support workers however currently they were unable to meet Birthrate + staffing levels due to insufficient midwives in post.

The service does not always assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

We observed chairs in different waiting areas which had torn seating fabric which was an infection control risk. We saw that equipment and the premises were mostly visibly clean, however we also found some areas were physically dirty. These were brought to the attention of staff.

Staff mostly used equipment and control measures to protect women, themselves and others from infection. We observed sufficient personal and protective equipment (PPE) was available. Hand hygiene audits showed 100% compliance for October, November and December 2024.

However, we looked at patient level and environment level infection risk audits and found that the antenatal and postnatal wards were not meeting expected standards for patient level risk with only 4 out of 10 patients audited in December 2024 having fully completed infection and prevention control documentation.

The lead IPC nurse had recently left her post to become a matron elsewhere within the organisation therefore support was provided by the Trust IPC Team and a dedicated Clinician and Matron who led on IPC and provided support to the clinical teams. Staff told us that the once fortnightly held IPC meetings had become difficult to arrange due to this and the additional staffing pressures. We saw meetings were inconsistent.

Infection prevention and control training was mandatory for staff and at SJUH this ranged from 75% in the antenatal clinic to 100% on the antenatal ward. The Trust’s target for completion was 80% The antenatal clinic and the postnatal ward (77%) were not meeting this standard.

Leaders told us infection was a consistent and important focus at each daily huddle discussion. Leaders told us about a rolling programme of audit that was carried out and supported constant improvement or change to practices where needed. All ward/unit areas displayed a clean star rating showing monthly compliance scores.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happened. Medicines were not always stored, administered and managed safely, in accordance with prescriber instructions and best practice guidelines to make sure that people who used the service were not placed at risk.

For example, we found medicines on the recovery unit were decanted from the delivery suite so there were loose strips of tablets rather than boxed strips. This is not best practice for the storage of medications. We also found that keypads on medicines rooms were not routinely changed increasing the risk that people no longer authorised to access areas were still able to do so. Additionally, we found the medicine trolley was not chained to the wall on the post-natal ward increasing the risk of it being taken by someone not authorised to do so. We further found that some patients experienced delays in discharge whilst they waited for prescribed medications to be dispensed.

Midwifery and medical staff were required by the trust to undergo Medicines Safety training every three years. At the time of the inspection, compliance stood at 87% for medical staff, 88% for the antenatal clinic, 89% for the postnatal ward, 98% for the antenatal wand and 99% for the delivery suite. The trust level of compliance required was 80%. Staff working in the maternity department at SJUH met the trust level of compliance for Medicines Safety Training.

The trust circulated a Maternal Medicine Newsletter for staff which included contact numbers and highlighted people to contact for support within the trust as well as important maternal medicine information and reminders.

The trust had a Medicines Code (accessible electronically) divided into chapters for ease of navigation for staff to follow. The standards for safe and secure handling and use of medicines at Leeds Teaching Hospitals NHS Trust were described in the Code. There was a chapter specifically for Non-Medical Midwife Prescribers. The trust used an electronic signoff for Patient Group Directions (PGDs) that was agreed through the Prescription Stationery Group which was a subgroup of the Medicines Safety Group.

FP10 prescription pads were stored in line with national guidance and staff could describe how they would identify if any prescriptions were missing.

Controlled drugs were stored in line with policy, checks took place and medicines were destroyed appropriately.

Staff told us there were very few nurse prescribers, which exacerbated some delay for women waiting in the day and ante natal unit.