Stroud Maternity Hospital Also known as Stroud Maternity Unit

On this page

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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse, and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

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

We have not awarded this service a score for Safe.

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

We scored the service as 2. The service did not always investigate incidents within the set timescale. Only 1 member of staff across the trust had been trained in the new incident‑review system, which will contribute to ongoing delays in completing investigations.

Stroud Maternity Hospital forms part of Gloucestershire Hospital NHS Foundation Trust, and staff at this location use the same reporting procedure for incidents. Women who were able to give birth at Stroud Maternity Hospital were assessed as being minimal risk, and serious incidents were low. Staff knew how to report incidents using the trust-wide system.

The Patient Safety Incident Response Framework (PSIRF) was introduced in 2024. PSIRF is a process for services to respond to patient safety incidents for the purpose of learning and improving patient safety. At the time of our site visit, only 1 member of staff had completed the specific training required to undertake formal patient safety investigations under the new PSIRF model. Actions were being implemented to train more staff in the use of this system.

Following our site visit we were told there were 3 incident reports that were overdue for investigation relating to Stroud Maternity Hospital as of November 2025. These were incidents of low or no harm. Senior staff from Stroud Maternity Unit attended the trust-wide maternity daily (Monday to Friday) safety flow meeting and all new incidents reported within the last 24 hours were discussed and areas identified for immediate learning were shared with staff. Overdue incidents were also reviewed and highlighted for investigation. There was a trust- wide Incident Response Safety Huddle (IRSH) where all incidents were reported for review. Senior staff told us this added an additional layer of executive oversight to ensure timely action was taken. Incidents were categorised to be presented back to IRSH and/or for referral to patient safety review panel.

Staff received feedback from investigations of the incidents they reported. Learning from incidents was shared with staff in several ways which included bulletins, emails and verbal updates at safety briefings during shifts.

Staff were debriefed and received support after a serious incident.

Information for women about how to make a complaint or provide feedback was available. Staff told us they knew the procedure to follow if a woman or their family/partner wanted to raise concerns. Senior staff told us they had received 1 complaint in October 2025. This was investigated and a response provided to the complainant within the timescales set.

Staff understood the Duty of Candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong. When senior staff reviewed incidents reported by staff they were also assessing if they met the duty of candour threshold.

We scored the service as 3. 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’s referral and admission processes ensured all information about the woman was received to determine if their needs could be safely met. Women were assessed for their suitability to give birth at this location at 35 weeks pregnant. The criteria included no previous caesarean sections and a body mass index (BMI) of below 35.

If women were concerned about their pregnancy, they were directed to the triage advice line and/or the unit at Gloucestershire Royal Hospital. There were no triage services at Stroud Maternity Hospital.

Staff followed a clear escalation procedure when a woman required transfer to the acute birthing unit at Gloucestershire Royal Hospital. Guidance was readily accessible to support staff, and electronic records enabled the acute hospital’s maternity team to access relevant information without delay.

Staff at this unit had access to the ‘flow matron’ who covered every shift and they were based at acute maternity unit. They managed staffing, flow, and any acuity concerns. Staff we spoke with said they would refer any concerns to them. There was also an on-call senior manager outside of these times.

Handovers and safety huddles across the Stroud Maternity Hospital involved all relevant members of the team. Shift changes included all necessary key information to keep women and babies safe.

Staff referred women from this unit to all the necessary healthcare and social care services. This was to ensure women and their babies had continuity of safe care, both within the service and post-discharge. Staff told us on discharge following the birth of a baby, they referred the women to the community midwives for follow up.

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

Staff were trained in safeguarding and understood how to raise alerts and acted appropriately. They knew who the safeguarding lead was and could seek advice when needed.

Safeguarding training compliance was above trust target. For safeguarding adults’ level 3, they had 1 member of staff who was overdue, but we were told they had been booked onto the training.

Staff told us they knew how to identify adults and children at risk and would work with partner agencies to protect them. There were procedures to protect women and babies, including restricting visitors who posed a risk.

During the site visit, no women were giving birth at Stroud Maternity Hospital; therefore, we were unable to review patient records relating to intrapartum (labour) care. However, staff said there was a system to identify women with safeguarding concerns, and they acted when necessary. Women were asked safeguarding questions relating to domestic abuse during antenatal contact, and we were told this was recorded within their maternity health records.

Systems, to maintain the safety of babies whilst on the unit, were tested several times a week to make sure they worked effectively. Staff told us they always responded to the alarms if they sounded. The unit was also locked and visitors needed to request access in and out.

We scored the service as 3. 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 to support their understanding of their care and treatment. During a consultant‑led antenatal clinic, birthing plans were discussed, and women and their partners were encouraged to share their views. Women told us they were fully informed about the progress of their pregnancy and any associated risks.

Staff understood risk management and used the Maternity Early Obstetric Warning Score (MEOWS) tool to identify women at risk of clinical deterioration. MEOWS is a recognised maternity care tool for monitoring pregnant and postpartum women. We saw on the ‘production board’ in the staff room data for August 2025 and staff were at 100% for the use of MEOWS.

Senior staff reported they had recently introduced a risk assessment tool to identify and manage the risk of pressure ulcers in women. Compliance with this tool was being audited, and results indicated that adherence was improving.

A weekly multidisciplinary (MDT) meeting reviewed women seeking care or birth outside of clinical guidance. We did not observe this as it was not taking place during our site visit.

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 maternity services at Stroud Maternity Hospital consisted of rooms used for the antenatal clinic, 3 birthing rooms, but 1 was not being used as a birthing room due to staffing and this was the smaller of the rooms without a birthing pool. The post-natal beds had been closed. The 2 remaining birthing rooms were ensuite and had birthing pools.

The service had sufficient equipment to support safe care for women and babies. This included monitoring devices and pool evacuation nets. Staff also undertook regular drills to practise the safe evacuation of a woman from the birthing pool in an emergency.

The unit operated 24/7, with women required to call before attending to give birth. It was fully secure, with swipe‑card access, monitored by clerical and maternity staff. During our visit, staff monitored entry to all areas and told us only 1 woman gives birth at a time due to staffing so they could easily oversee who entered and left the unit.

Equipment used in an emergency was checked daily and was ready in case it was required. This included oxygen cylinders which were all in date. Action-cards/algorithms (which included what medicines to use in an emergency) were stored on the emergency trolley for staff to reference information on how to manage an emergency, for example, postpartum haemorrhage (PPH). PPH is heavy bleeding after birth.

Senior staff told us all emergency trolleys across the trust contained all the same equipment, so they were standardised. We noted ligature cutters were stored in secured trolleys which staff had access to in an emergency.

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.

Staffing levels at Stroud Maternity Hospital consisted of 1 band 6 midwife and 1 band 3 maternity care assistant (MCA) on each shift. An on‑call system supported escalation, with 1 midwife available during the day and 1 overnight, supplemented by a county on‑call midwife. Women received 1‑to‑1 care during labour. A staffing tool had not been implemented to determine staffing levels.

Senior staff monitored ‘red flags’ in maternity staffing monthly. A midwifery red flag event is a warning sign that something may be wrong with midwifery staffing. In September 2025, the number of red flags recorded across the trust’s maternity services was 11, and staffing factors was 478. These included delays in providing pain relief and unexpected staff absences. An action plan had been devised to improve compliance with red flag incidents. it was not clear if these red flag incidents related to this location as they were reported trust-wide.

Staff were up to date with mandatory training, completing the required 3 training days per year, and compliance at Stroud Maternity Hospital exceeded the trust target. Staff also accessed adaptive training delivered in a simulated community setting, which they reported provided more realistic preparation for home births and standalone birthing centres.

The trust had a flow coordinator matron based at the acute trust on every shift. Flow coordinators were supernumerary and had oversight of the staffing, acuity, and capacity within the maternity services across the trust. They reviewed and adjusted staffing levels and skill mix daily according to the needs of women. Staff from Stroud Maternity Hospital said they would contact them if they had any concerns and if their local leaders were not on site.

Senior staff were looking at different methods on how to reach and engage staff for training on different topics to meet all training needs, for example, word of the week, emails, and a closed group social media channel.

We reviewed recruitment files for employees and found the trust was compliant with the necessary regulatory requirements. Staff had the necessary checks before commencing employment with the service to ensure they were suitable to support women and babies.

Qualified staff had their registration details checked, and there was a system to monitor this. Also, a process for monitoring revalidation was established and compliance was regularly reviewed.

The trust-wide sickness rate for nursing and midwifery staff in the maternity core service saw sustained reduction from 5.9% in December 2024 to 4.1% in April 2025. This then rose again in the most recent month of June 2025 to 5.5%. This was still an improvement from the elevated sickness rates experienced by this staff group around May 2024 which sat at 7.1%. As this was trust-wide data, data relating to Stroud Maternity Unit was not clear.

Nursing & midwifery staff leavers peaked in September 2024 (10.3%) but have since reduced to much lower numbers, with the lowest recorded across the period in the latest data available (1 in July 2025). This was trust-wide data and included Stroud Maternity Hospital.

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 adhered to infection control principles, including handwashing. Staff wore their own clothes at Stroud Maternity Hospital but had access to personal protective equipment (PPE) to wear as required and during births.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date.

Staff had access to domestic and clinical waste bins, and these were emptied regularly. Sharps and hazardous waste bins were stored safely.

Stroud Maternity Hospital areas were clean, furnished, and well-maintained.

An audit for Hand hygiene compliance carried out in October 2025 was 100%. Staff explained to us how they cleaned the birthing pools when they had been used. However, we did not check records to confirm this but ‘I am clean stickers’ were in place on both birthing pools, which included the date they were cleaned.

We scored the service as 2. The service ensured that medicines and treatments were safe and met people’s needs, capacities, and preferences. However, temperature was not always monitored for medicine storage areas. Also, there was inconsistent clinical pharmacy support, resulting in a lack of medicines reconciliation.

Medicines were administered using exemptions for midwives. Midwives' exemptions are legal provisions allowing registered midwives to supply and administer specific Prescription Only Medicines (POMs), including certain controlled drugs, on their own initiative without a doctor's prescription or a Patient Group Direction (PGD). PGDs are written instructions for named healthcare professionals (like midwives or nurses) to supply or administer specific medicines to patients who fit defined criteria, without a doctor's prescription for each patient. These exemptions cover essential medications for pregnancy, labour, and postnatal care. All women had venous thromboembolism risk assessments (VTE) conducted on admission. Medical history for women was carried out by the midwifery staff on admission. However, there was no clinical pharmacy support for the maternity service. We were not assured how or whether the medicine reconciliation process was carried out. Medicine reconciliation is the process of accurately listing a person’s current medicines. This could be when they are admitted into a service or when their treatment changes. Senior staff told us Stroud Maternity Unit was a standalone midwife-led birth centre for women assessed as suitable to give birth there. Postnatal beds were closed at the time of inspection. Midwives completed medicines histories on admission and managed medicines in line with midwives’ exemptions and relevant Patient Group Directions (PGDs).

Midwives used PGDs to dispense medicines to patients as to take out medicines (TTO’s). The PGDs had been reviewed, and there were governance systems for their use. However, we found one of the medicines being dispensed was not labelled as per the trust’s own policy and national guidance.

Medicines, including controlled drugs (medicines requiring additional control due to the potential of misuse) were stored securely. Medicine fridge temperatures were recorded and monitored. However, the room temperature for medicine storage areas was not monitored or recorded. This was reported to senior staff during our site visit.

The staff conducted regular medicine management audits. However, the audits did not identify the gaps for room temperature monitoring and labelling of medicines that we found during the inspection.