Good Hope Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We rated safe as requires improvement. The service was not able to always manage patient risks safely. This was due to insufficient staffing, lack of completion of risk assessments and delays for patients in receiving care and treatment. There was a delay in both reporting incidents (and some concerns they were not being reported) and in investigating them for learning or action. At our last assessment, we rated this key question requires improvement. At this assessment, the rating remained requires improvement. This meant people were not always safe and were at risk of 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.

Staff did not always listen to safety concerns or consistently investigate and report safety events. Staff were aware of what incidents were, but these were not always reported. For example, on 15 March 2025, a woman experienced a delayed episiotomy using blunt instruments. Although the midwife documented this should be reported, it had not been submitted as an incident by the time of our visit on 26 March 2025. Managers acknowledged delays in incident reporting and told us efforts were underway to improve this.

The service reported a 20 to 30% reduction in incidents reported due to a change in the incident reporting system. Senior managers were aware of this issue and had implemented measures to address it. These included a rotation programme for Band 5 midwives into the governance department for 2 to 4 weeks to enhance understanding of incident reporting and governance. Quality and safety midwives also reviewed handovers to identify unreported incidents. For instance, a review of re-admissions the week prior to our visit revealed 9 unreported incidents.

Leaders promoted a proactive and open safety culture. Staff reported knowing how to raise incidents and felt empowered to do so, although the formal reporting system was described as time-consuming.

Managers regularly reviewed incidents to identify immediate actions. Incidents were discussed in clinical governance meetings, and learning was shared through various channels, including a governance newsletter and a quarterly protected governance day. Staff reflected on feedback to improve care. For example, there had been an increase in postpartum haemorrhages due to not giving post-birth medicines promptly enough. There was a workstream which was looking into the reduction of postpartum haemorrhage and implementing improvements such as ensuring optimal birthing positions.

Managers provided debriefs and support following serious incidents, which were reported in line with trust policy. Professional midwifery advocates supported staff after serious incidents.

Delays in reviewing and closing incidents impacted on the ability to learn from incidents and was a risk to women and babies. At the time of reporting, there were 353 open incidents, with 233 overdue. These delays were due to incident handlers being redeployed to clinical duties during periods of high acuity. This was reported bi-monthly to the senior midwifery team.

Staff understood the duty of candour and were open and transparent when things went wrong. In October 2024, 96.5% of duty of candour notifications were completed within 10 days. Efforts continued to ensure final notifications were completed promptly following reviews.

Communication of information about women between health professionals was inconsistent. Despite previous recommendations, the SBAR (Situation, Background, Assessment, Recommendation) communication tool was still not reliably used. We reviewed 5 patient records and found SBAR documentation was incomplete in all 5 records. An April 2025 audit by the Healthcare Safety Investigation Branch found only 43% compliance with digital handovers. Internal data showed SBAR handover completion rates were particularly poor between the ward and delivery suite at 25%. The governance team had picked up on poor completion of SBAR and had commenced work to improve this.

The service chose to continue offering midwifery continuity of care (MCOC) after the national requirement for MCOC targets was removed in September 2022 due to national workforce pressures. The focus remained on supporting women in deprived areas who required social and interpretation support. However, only one midwife was available to provide this MCOC care, resulting in a high caseload and limited access to clinic space. This led to an increase in home visits, reduced efficiency, and raised concerns about the ability to maintain safe and effective care. The service was unable to expand the MCOC team as this was dependant on having no midwife vacancies; the trust had an 8 to 10% vacancy rate. Further MCOC rollout had been paused but remained on the service's risk register.

The service collaborated with healthcare partners to improve care systems and safety. However, audit data from the maternity assessment centre between 11 January and 24 March 2025 showed delays in midwifery care on 12 out of 73 days. There were delays in medical reviews on 64 days, with doctors meeting hospital set review targets on only 9 days.

Women scheduled for induction of labour (IOL) did not always have their IOL commenced as planned. These delays were considered midwifery "red flags" and were recognised and addressed through senior review and prioritisation. Midwifery red flags were a warning sign something may be wrong with midwifery staffing.

Delays for women awaiting IOL from home were not recorded or reported. The managers had limited oversight around these delays and the impact. However, the service offered fetal heart monitoring and had an IOL improvement project underway.

Placental histology and perinatal post-mortem services, provided externally, had been on the trust's risk register since October 2023 due to significant delays. These delays affected timely completion of perinatal mortality review tool (PMRT) cases, learning from incidents, and the psychological well-being of bereaved parents. A review using the PMRT and the patient safety incident response framework (PSIRF) data identified delays in emergency caesarean sections due to operating theatres not being immediately available. These delays resulted in decision-to-delivery times exceeding national guidance, which had an adverse impact on both maternal and neonatal outcomes.

The service collaborated with individuals and healthcare partners to understand what safety meant to them and how best to achieve it. Staff demonstrated a clear understanding of how to protect women from abuse and worked effectively with external agencies to do so. Data indicated 89% of staff were trained to level 3 in safeguarding adults and children which was slightly below the trust target of 90%

Staff were knowledgeable about how to make safeguarding referrals and knew who to contact when concerns arose. There was a dedicated safeguarding team for maternity with daily discussions and handovers occurring regularly. When safeguarding concerns were identified, a flag was added to the woman’s electronic record. Staff reported vulnerable women had birth plans developed with input from the safeguarding team, and safe discharge plans were arranged during antenatal appointments; we read individual plans for discharge in patient records.

A safeguarding policy and pathway were accessible to staff, alongside a baby abduction policy. Practice drills for baby abduction were conducted, with the next one scheduled for April 2025. Staff were familiar with the policy, and ward areas were secure with monitored doors. An abduction box was available on the ward to support staff in such events.

Staff routinely asked women about domestic abuse. However, recent changes to visiting hours meant a nominated person could always be present with the woman, which we were told limited opportunities for staff to speak with women alone.

Staff could provide examples of how they protected women from harassment and discrimination, including those with protected characteristics under the Equality Act. They demonstrated an understanding of equality and diversity and ensured care and treatment aligned with the Act.

Staff were also aware of the Mental Capacity Act 2005 and its relevance to the women in their care. Safeguarding and mental health needs were regularly discussed during handovers; we observed this on assessment.

The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people's needs that was safe, and supportive and enabled people to do the things that mattered to them.

Staff used nationally recognised tools to identify risks of deterioration in women and babies, but these were not always completed. Staff used national tools such as the Modified Early Obstetric Warning Score (MEOWS) for each woman and Newborn Early Warning Scores (NEWS) for each baby. In all 5 sets of notes reviewed NEWS were inconsistently recorded. For example, in 1 case, a baby exposed to meconium had no observations recorded for 7 hours post-birth. Managers confirmed no audits were conducted to monitor MEOWS or NEWS compliance.

We reviewed 5 sets of notes and found MEOWS was completed for each patient. However, it was difficult to follow as it was documented in different places, some on paper and some on electronic systems.

Sepsis documentation was inconsistent. Although there was a maternity sepsis pathway, it was under review by the advanced care practitioner midwife to improve documentation and treatment processes.

In March 2025, the service introduced mandatory training on recognising deteriorating patients and aligning care with sepsis guidance. Audits were planned to monitor treatment timeliness but had not been completed at the time of assessment.

A quality improvement project led by an advanced care practitioner midwife focused on managing deteriorating patients. Actions included enhanced education on Maternal Early Obstetric Warning Scores, E-learning modules and bespoke training for critical care outreach teams.

In February 2025, an audit of labour assessment reviews showed 69.2% compliance. These assessments, conducted hourly, evaluated maternal and fetal wellbeing. Improvement actions included targeted training and communications at daily briefings.

The same month, the service audited compliance with `fresh eyes' reviews, hourly checks by a second clinician, and found 50% compliance against an 80% target. Increase in ward acuity was cited as a reason for delays in completing `fresh eyes' checks. Compliance had improved from 35% in August 2024. Leaders acknowledged further improvement was needed and established an intrapartum forum to share learning, audit outcomes, and ensuring adherence to national guidance.

There was not always a high-dependency trained midwife on each shift. Although managers aimed to ensure there was, it was not consistently achieved.

A high-dependency unit bed was available on the delivery suite, and training on enhanced care had begun. There was a practical obstetric multiple professional training and a further course for the care of critically ill pregnant or postpartum women; there had been 28 midwives signed up to complete this course. Data showed 75% of midwives, 79% of midwife support workers and 71% of theatre staff had completed practical obstetric multiple professional training which was below the trust target of 90%; all doctors and anaesthetists training compliance was above 90%.

The trust had a fetal surveillance day. Figures from March 2025 showed 82% of midwives had completed this, 87% of doctors, and 89% of consultants; these were all below the trust target of 90%.

The service cared for women from 32 weeks' gestation onwards. Women in labour before 32 weeks were transferred to the trust's other maternity service at Birmingham Heartlands Hospital following a multidisciplinary risk assessment.

Newborn risk assessments were completed using recognised tools and reviewed regularly. While transitional care was provided, there was no dedicated area. Babies needing intravenous antibiotics were transferred to the special care baby unit by nursery nurses or support workers, with mothers invited to accompany them.

Staffing levels were not always sufficient to manage maternity telephone triage in line with Royal College of Obstetricians and Gynaecologists Maternity Triage (Good Practice Paper No. 17). There was a designated midwife on each shift allocated to respond to and manage the triage telephone line. The service was looking at centralising this with its other maternity site as leaders felt this would be more efficient for the safe triage of women.

Women did not always receive treatment within agreed timeframes and national standards. The triage process followed evidence-based practice and patients were graded in accordance with the seriousness of their presenting complaint. There was a colour-coded scale to give a visual appearance of those patients needing more urgent review. We reviewed 5 sets of notes and 2 out of 5 had no documented triage, 1 had no documented arrival time and 2 out of 5 women risks were inappropriately colour-coded for their clinical priority. For example, a woman with reduced fetal movements was rated as green instead of amber.

Women and babies were put at risk of potential harm due to continued delays in medical reviews. Women attending the maternity assessment centre were not always seen in line with national recommendations and local compliance timescales. From 11 January to 24 March 2025, there were 21 days where delays were reported by the service. The service reported during 1 March 2025 to 24 March 2025, there were 4 days where compliance was in line with recommendations. However, there were also 2 days during this period where there was zero compliance with medical reviews.

Following feedback to the senior leadership team, the service provided an action plan to reduce delays and risks to improve compliance with the timeliness of medical reviews.

Risk assessments were not consistently completed for women attending triage. One woman did not have a risk assessment completed during her first attendance, and the second attendance lacked documented timings.

Staff did not always reduce the risks to women and their babies. Staff did not consistently use the hourly `fresh eyes' approach to carry out fetal monitoring safely and effectively. We reviewed 3 sets of notes of women having continuous cardiotocography and 2 of them had delayed `fresh eye' assessments, with some delays over 1 hour. Managers audited fresh eye's compliance monthly. Results for March 2025 showed 70% compliance.

Fetal heart rates were not always monitored in line with national guidance which put women and babies at risk of potential harm. For example, we looked at 1 set of notes where a woman was admitted to the midwifery-led unit in labour at 12pm and no fetal heart rate was done until 1.15pm. The baby was born at 3.04pm and no fetal heart rate was recorded between 1.30pm and 3.04 pm. National guidance states this should be done every 5 minutes in the second stage of labour. Two sets of intrapartum records showed the fetal heart was monitored by intermittent auscultation and was not auscultated every 5 minutes in the second stage of labour in accordance with national guidance, which was therefore not being followed.

The service did not always risk assess the women who delivered on the midwifery-led unit. There was a list of criteria for women who were able to safely deliver on the midwifery led unit and this was not always followed. For example, on 26 March 2025, a woman laboured on the midwifery-led unit and was found to have additional risk factors during the birth. The risk factor of meconium should have triggered immediate escalation to paediatricians for them to attend the birth. The baby was born on the low-risk midwifery led unit without recognition or action to ask a paediatrician to be present despite a reasonable timeframe to call them to attend. This was against guidelines. Managers were going to review the midwifery led unit guidelines and update to national evidence-based practice.

The service did not collate postpartum haemorrhage data for women who bled less than 1,500 millilitres in volume. Staff only collated and reported data for major obstetric haemorrhages over 1,500 millilitres. We were told women's postpartum haemorrhage rate had slightly increased and it was their main incident theme. The governance team had completed a thematic review and found the postpartum haemorrhage risk assessment completion to be inadequate. They were increasing education and teams were being encouraged to complete it. Following the assessment, the service included monitoring 500 to 1499 millilitres as part of their dashboard.

The service completed the World Health Organisation surgical checklist for most patients. This was completed fully in 3 out of the 4 surgical notes we reviewed. We watched the World Health Organisation checklist being completed during a caesarean section and found the staff engaged with it and it was completed appropriately. However, we reviewed the 5 Steps to Safer Surgery and found the debrief was not completed for any patient within the last few months. Staff told us they did a debrief but this was not documented; this was not in line with evidence-based practice.

Staff liaised with mental health colleagues as required. They were available 24 hours a day, 7 days a week. Staff explained when and how they could seek assistance to support women with mental health needs. There was a woman who had acute mental health needs while we were on site. There was a plan to ensure they had the support they needed. This included a 4-day extended stay following birth and follow-up support in the community. Staff completed risk assessments and arranged one-to-one care for women who they thought were at risk of self-harm or suicide.

Shift changes and handovers included all necessary key information to keep women and babies safe. During the assessment, we attended 3 handovers and found all the key information was shared. Staff had daily safety huddles to ensure all staff were up to date with key information. Each staff member then had a one-to-one handover with the midwife by the bedside to ensure all important information was handed over and they had introduced themselves to the woman. However, we saw this was not always documented in the woman's notes.

Women did not always have an antenatal ultrasound scan in line with guidance. There were limited appointments for women who were at high risk to have an urgent antenatal scan, and this often exceeded the recommended times; this was on the risk register.

Women were offered multiple antenatal scans when they were not always indicated. For example, a woman had reduced fetal movement and was offered an ultrasound scan after their first episode due to their ethnicity; this was not in line with guidance. The scan showed the baby was on the 10th centile and was booked for a further scan to check the baby's growth. The woman had 3 subsequent scans, which were not in line with guidance. The baby remained on or over the 10th centile which did not require an ultrasound scan.

We were told new reduced fetal movement guidance had been produced. All women who were 18 to 23+6 weeks gestation would have an artery doppler and if there was an identified risk of fetal growth restriction, the baby was put on a surveillance pathway; this new process was anticipated to allow additional ultrasound scan availability.

Women who required induction of labour were mostly brought in for induction in line with guidance. Where there were delays, which were mostly due to a lack of beds, the consultant obstetrician reviewed the list of women and brought them in based on their risk. They induced 2 high-risk and 4 low-risk women per day. The list was reviewed twice daily, and all women were brought in for a cardiotocograph, and assessment and had their plan of care reviewed.

We spoke with 2 patients who had been induced, and both were induced in line with national guidance and policy.

The managers completed operational pressure escalation levels status every 4 hours. This was a red, amber, and green (RAG) rating assessment of the pressures the departments were under. At the time of the assessment, the operational pressures escalation level status was mostly green but moved to amber later in the afternoon due to staffing pressures. This was discussed twice a day at staffing meetings with managers present. Staff told us they were often short-staffed, particularly in the afternoons with no solution from managers.

The service ran regular specialised clinics to support women. These included diabetic clinics, endocrine clinics, substance misuse clinics, and a mental health clinic. These clinics reflected a multidisciplinary and holistic approach to maternity care, ensuring women with additional health needs received tailored support throughout their pregnancy journey.

Since March 2025, the service had been trialling `Martha's Rule' in maternity which was part of a national pilot prior to national role out. It allowed families to request a rapid review by critical care outreach. At the time of the assessment, it had not yet been used.

Staff did not always have access to the necessary equipment and facilities to consistently deliver safe care. For example, the midwifery-led unit was found to lack a functional pair of episiotomy scissors; the only available pair was blunt, and no alternatives were accessible when needed which led to a poor patient experience.

Staff did not make sure equipment, and facilities supported the delivery of safe care. For example, flammable items that were not stored in a metal flammable cabinet as per Control of Substances Hazardous to Health (COSHH) Regulations 2002. We found out-of-date equipment in the midwifery-led unit clinical room. This included blood bottles, a delivery pack, and syringes; we raised this with the managers who ensured they were disposed of immediately.

The design of the maternity environment followed national guidance. The unit was fully secure, with monitored entry and exit points in each area. Security personnel were present 24-hours a day, 7 days a week, at the main entrance, verifying visitor identification against a daily approved list.

Women had access to call bells, and staff responded promptly. Daily safety checks of specialist equipment were being carried out, addressing a previous assessment finding where such checks were not consistently performed.

The service had sufficient suitable equipment, including portable ultrasound scanners, cardiotocography machines, and observation monitoring tools, to support safe care for women and babies.

Facilities were not adequate for partners staying overnight. Staff reported instances of partners sleeping on the floor or in beds with patients. The service recognised the challenges and had approached charities to support with funding for convertible armchair/beds. Visiting hours for birthing partners had been extended to 24 hours a day.

A soundproofed bereavement suite was available on the delivery suite, designed in line with national guidance. It was sensitively decorated and allowed families private space to grieve.

Two well-equipped theatres were located adjacent to the delivery suite, with a recovery area. While elective caesarean sections were performed at Birmingham Heartlands Hospital, the Good Hope Hospital unit undertook emergency theatre activity. There was a bed equipped for level 1 high dependency care in the delivery suite.

Leaders reported ongoing environmental and estate improvement projects, with 49% of actions completed as of February 2025.

Clinical waste was managed safely. Sharps bins were correctly labelled and not overfilled, and staff used appropriate bins for waste segregation.

The service did not always have enough staff to meet women's needs due to high vacancy rates. Managers moved staff according to the number of women in clinical areas and acuity.

During the assessment, the number of midwives and maternity support workers did not meet planned staffing levels. Daily shortages of midwives were reported. Staff were moved between areas to maintain safety.

A manager was assigned daily to a `safety and capacity' role, conducting walkarounds and coordinating staffing adjustments. Twice-daily meetings were held to reallocate staff based on acuity across both Good Hope Hospital and Birmingham Heartlands Hospital. A daily redeployment list identified staff who might be moved to different areas, although staff told us this tended to cause them anxiety and uncertainty. The service had introduced several initiatives to reduce anxiety and to support staff including moving staff to an area where they were most comfortable and suited to their skill set.

Shortages in staffing levels posed risk of potential harm and delays in care. According to trust board papers from March 2025, the delivery suite met acuity staffing levels for only 65% of shifts in January 2025. There was a shortage of up to 2 midwives per shift for 31% of the time, and in 4% of shifts, the shortfall was 2 or more midwives. Where there were staffing shortfalls, staff were redeployed to higher-risk areas, and delays occurred for women awaiting induction of labour both at home and in hospital. The service did not use agency midwives. However, there had been a noticeable reliance on internal bank staff to support safe staffing levels.

In January 2025, 61 staff were redeployed from their main area of work to another area. There were 7 reported incidents where midwives could not take a break, 5 escalations to the manager on call, and one maternity service divert.

The delivery suite had 13 midwives on maternity leave, with their posts unfilled and vacancies remaining. Most days experienced staffing shortfalls, often covered by bank staff or left unfilled. There was a reliance on bank staff to cover staffing shortfalls, but these shifts were not always filled which led to inadequate staffing in some areas. Fill rates for January 2025 were 77% in the day and 73% at night.

A recruitment drive had led to hiring some new Band 6 midwives, reducing the vacancy rate. However, this resulted in a relatively inexperienced workforce and increased pressure on senior staff to provide support. To support less experienced staff, clinical practice support midwives were assigned to shifts with a higher number of Band 5 midwives.

Managers reviewed staffing levels and skill mix in accordance with national guidance and completed a maternity safe staffing workforce review. The review identified a continued shortfall in midwifery staffing to meet patient acuity. This was on the service's risk register, and a business case was being developed to including staffing recommendations.

There were inadequate numbers of diabetic midwives to maintain the service required to keep diabetic women safe during pregnancy. The service had worked to mitigate this risk by increasing staffing, putting extra clinics on, recruiting 2 additional maternity support workers to support the specialist midwives and had a quality improvement group with regular meetings with the head of midwifery to monitor the risk.

The delivery suite had 2 Band 7 midwifery shift coordinators scheduled on each shift. However, due to staffing constraints, there were occasions when only 1 was present. These coordinators were supernumerary, overseeing staffing, acuity, and capacity. Compliance with the supernumerary requirement ranged from 91% to 100%, between November 2024 and January 2025.

The service utilised an acuity tool to ensure safe staffing levels across all shifts and departments. Acuity data was submitted every 4 times within 24 hours, generating a red-amber-green rating called the operational pressure escalation levels (OPEL) status. This information was shared across the Local Maternity and Neonatal System (LMNS) and discussed in staffing meetings. The LMNS is a partnership of people involved in maternity and neonatal services, working together to improve services. On 25 March 2025, the OPEL status began as green but changed to amber due to staff sickness.

There was evidence of strong collaboration within the LMNS to improve services. Senior leaders held twice-daily meetings to review acuity, staffing, and associated risks, in line with the OPEL process. Staff were redeployed as needed to maintain safe care. When internal redeployment was insufficient, the escalation policy allowed for community midwives to be brought into the hospital, suspending the home birth service.

Maternity theatres were appropriately staffed, with contingency plans for the use of a second theatre. Support from the main theatres was consistently available when required.

The service did not consistently report `red flag' staffing incidents in accordance with National Institute for Health and Care Excellence guideline NG4. Between 1 January and 31 March 2025, 111 red flags were reported, primarily due to delays in time-critical activities and induction of labour. Notably, delays for women awaiting induction from home were not reported as red flags; this was not in line with national guidance. Board papers from March 2025 reported 46 cases of delayed induction of labour, posing potential risks to women and babies.

Medical staffing levels were insufficient in triage to consistently provide timely care. Between 11 January and 24 March 2025, only 60% of women were seen within the recommended timeframe in triage, which was set by the trust, against a target of 85%. On 2 days during this period, no women were seen on time, and only 9 days met the target.

Triage-service staffing did not meet national standards. The service was staffed by 1 midwife and 1 support worker, and 1 resident doctor during weekday hours. While the doctor was ringfenced to triage they were often pulled to the postnatal ward to assist and were often not in triage before 11am. The weekend coverage relied on on-call doctors.

With the exception of triage, the service maintained a good skill mix of medical staff per shift and regularly reviewed staffing needs. Locum doctors were used to fill staffing gaps and received full inductions. Consultants were on-site from 8am to 5pm and on-call outside these hours. Consultant ward rounds occurred at 8am and 8pm. Staff reported consultants were accessible and approachable. However, the service's risk register highlighted an inadequate obstetric skill mix and gaps in the junior doctor rota, affecting both patients and staff. Leaders reported an obstetric and gynaecological workstream aimed at increasing staffing and service provision, which was 19% complete as of February 2025.

A dedicated anaesthetist was available 24 hours a day, 7 days a week for the labour ward and conducted postnatal reviews for women who had received anaesthetic care in the previous 24 hours.

International trainees on a 2-year programme supported care delivery after a 2-week observation period. Most medical staff felt supported through supervision and development opportunities. Observations showed a supportive environment during clinical procedures. However, some international trainees reported feeling under-supported and undervalued, with concerns about equitable access to learning opportunities.

All midwifery staff held the appropriate training and qualifications to provide safe care to women and their babies. Staff reported the hospital offered good training, education, and support. There was a maternity training programme, and it was reviewed annually. Training was integrated into staff rotas to encourage attendance, although staffing gaps sometimes made this challenging.

According to the board papers from March 2025, 83% of midwives and 84% of maternity support workers had completed mandatory obstetric training. Both figures fell below the service's compliance target of 90%. In contrast, obstetric trainees, obstetric consultants, anaesthetic trainees, and anaesthetic consultants all exceeded the 90% compliance threshold.

A preceptorship program was available for Band 5 midwives, supported by clinical preceptorship midwives who worked alongside them to aid development and sign-off competencies.

Maternity support workers received 1 dedicated training day per year in addition to mandatory training. In preparation for the re-banding of these roles to Band 3, a second study day was planned, which would include the competencies required for the new banding.

The service ensured staff were competent in their roles. Managers conducted appraisals and provided support and development opportunities. There was a practice development team to support midwives.

Managers ensured staff received specialist training where required. For example, 2 midwives had received funding for a 3-year advanced care practitioner course.

The service effectively assessed and managed the risk of infection. Staff consistently used appropriate equipment and control measures to protect women, themselves, and others. Equipment and premises were kept visibly clean.

Maternity service areas were well-maintained, with clean and suitable furnishings. There were effective systems to ensure deep cleaning and decontamination of rooms following patient discharge or transfer. Cleaning records were mostly up to date and demonstrated regular cleaning across all areas. However, the delivery suite had recently introduced a birthing pool cleaning checklist, which had not been completed on 5 out of the 10 days since its implementation.

Staff adhered to infection prevention and control protocols, including the use of personal protective equipment. Hand hygiene practices followed the `5 moments for hand hygiene' standard. Monthly audits on hand hygiene and infection prevention and control were conducted across all maternity areas. Results from between 1 January 2025 to 1 April 2025 ranged from between 93 to 100% for hand hygiene but not all areas were completing the audit monthly. There was an action plan to improve compliance. Environmental audits for the same timeframe ranged from 86 to 100%.

Audit results were displayed in ward areas. However, some displayed audit data that was significantly out of date. For instance, Ward 1 still displayed infection prevention and control audit results from 2019.

Staff cleaned equipment after each use and labelled it to indicate the last cleaning date. Hand sanitising gel dispensers were readily available at all entrances, exits, and clinical areas for use by staff, women, and visitors. Staff used hand sanitiser upon entering clinical areas and washed their hands after contact with people.

The service made sure medicines and treatments were safe and met people's needs and preferences. The department had mostly safe systems for appropriate and safe handling of medicines to ensure people were given their medicines as prescribed. We reviewed 10 sets of medicine prescription charts and found them all to be appropriately and correctly completed.

Most medicines were locked and secure and stored safely in line with recommended practice. However, 1 medicine was not locked away and not stored in the fridge in accordance with manufacturer's guidelines. We raised this with the managers.

All clinic rooms seen were neat and tidy. Controlled drugs were stored safely and securely with access restricted to authorised staff. Checks were undertaken and recorded by 2 staff in each area twice a day. We checked the balances for controlled drugs in 2 different maternity areas and found them to be correct. Full and detailed controlled drug audits were undertaken by pharmacy quarterly.

Resuscitation medicines required in an emergency were available and followed Resuscitation Council (UK) guidance. Emergency medicines were stored in tamper-evident sealed boxes prepared by pharmacy and oxygen cylinders seen were within expiration date. Records showed staff undertook daily safety checks on medicines and equipment.

However, medicine room storage and refrigerator temperatures were not all monitored daily. Where temperatures were out of range, these were not always acted upon. For example, the fridge in the delivery suite was out of range for most days in March 2025, but no documented action had been taken. We raised this with the manager who said a new fridge had been ordered. Fridge checks were not consistently completed on the midwifery-led unit. At the time of our assessment, the fridge had only been checked once in March 2025.

There were processes to ensure people received their medicines as prescribed. Medicine administration records were documented including recording a reason if a medicine had not been administered. We reviewed 10 paper medicine administration records, and all medicines were given as prescribed.

We observed midwives using a red apron system during medicine rounds to alert people that they were administering medicines. This ensured staff had limited interruptions during medicine rounds to prevent medicine incidents. This was in line with evidence-based practice.