John Radcliffe 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 looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that women were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination.

At our last assessment, we rated this domain requires improvement.

At this assessment, the rating remained the same, we rated the safe domain requires improvement This meant women were safe and protected from avoidable harm.

Requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

We have not awarded this service a score for Safe.

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

The evidence showed a good standard. The service had a positive, supportive reporting culture, and leaders reviewed the processes to identify, report and learn from incidents, based on openness and honesty.

There was a healthy reporting culture within maternity services. Data showed over three thousand reported incidents involving all aspects of care and management of services.

The September 2025 ‘Maternity Quality Report’ data showed 78 overdue incidents which equates to 3% of reported incidents. The incident data and investigation reports showed recurring themes. For example, cardiotocograph (CTG) fresh eye reviews (a safety practice in maternity care requiring a second clinician (midwife or obstetrician) to independently review a continuous electronic fetal monitoring trace), and escalation of concerns during labour and post-partum haemorrhage.

Managers used audit data to inform multidisciplinary meetings and the implementation of ‘Triangulation and Learning Committee (TALC’) to make improvements and monitor progress.

Managers held daily multidisciplinary incident meetings, shared learning and reported into the trust’s Safety Learning and Improvement Conversation (SLIC).

The patient safety team reviewed incidents in line with the “Patient Safety Incident Response Policy (2023). Staff involved in reviews followed the “Patient Safety Incident Response Plan (2023) to select the appropriate investigation method and review tool.

Staff understood their responsibilities and knew what incidents to report and how to report them via an electronic form on the trust’s intranet.

A muti-disciplinary team used the “Perinatal Mortality Review Tool” (PMRT) digital system to conduct thorough reviews of the care of babies that died from 22 weeks gestation. The multi-disciplinary team included: a specialist midwife, obstetrician, neonatologist, senior midwife, patient safety specialist, a member of the Oxford Maternity and Neonatal Voices Partnership and external representation from other acute provider partners. The aim was that the reviews provided answers to bereaved families and the opportunity to implement learning where this was required.

Managers reviewed and shared national patient safety alerts. We saw examples of this in reports to the “Maternity Clinical Governance Committee” via the “Maternity Quality Report.”

Staff used a multidisciplinary approach to investigations and involved families in the review process and developed action plans and shared learning with the relevant teams.

Staff understood ‘Duty of Candour.’ They were open and transparent and gave patients and families a full explanation when things went wrong.

Staff received feedback from investigation of incidents, both internal and external to the service. Leaders created newsletters and managers fed back outcomes to inform practice.

There was evidence that leaders made changes because of feedback from families and staff. The Practice Development Team included major themes identified from incident reviews in the following year’s training schedule.

Staff had access to professional midwifery advocates (PMA) who supported staff to debrief and facilitated staff learning from incidents.

Women and families knew how to raise concerns or make complaints. The service had ‘Say on the Day’ devices (smart screens on stands) in each area for people to provide feedback. The trust’s website explained how to make a complaint and signposted people to the complaints department.

However, the data was not always easy to interpret. The trust is required to report delays in induction of labour. Trust incident data showed 32 reported incidents between November 2024, and October 2025 related to long delays that affected other aspects of care. In contrast, NICE Red Flag monitoring data recorded 206 delays over 24 hours between April and October 2025. We raised this discrepancy with the trust. Leaders told us the difference reflected the different thresholds and purposes of each dataset. Red Flags are performance indicators and are not always reportable incidents under the Patient Safety Incident Response Framework (PSIRF).

Incident data indicated 19% of reported events were graded as moderate to severe harm, which was slightly higher than the national average of 10 to 15%. Key themes included 261 unplanned term admissions to the neonatal intensive care. The hospital was a main tertiary centre with higher rates of complex cases which when combined with a strong reporting culture could explain the slightly higher than average reporting of moderate to severe harm.

The evidence showed significant shortfalls in the standard of care in some areas of maternity services.

We found significant issues with systems designed to make improvements as they were not always robust enough to manage safety well. We found care issues in several areas. We raised concerns with service leaders, and they responded quickly to implement strategies to mitigate risk. However, the service collaborated with women, families, and healthcare partners to establish safe systems of care.

As a result of internal surveillance and feedback from service users the service initiated the introduction of the ‘Induction of Labour (IOL) Shared Principles Framework’ (2025) to strengthen best practice, manage significant delays and ensure consistent escalation and reporting. The framework included standardised processes, risk‑mitigation actions and checklists to support safer and more consistent care.

When the framework was implemented in 2024 data showed promise with delays over 24 hours being reduced by up to 54% in early 2024. The trusts quarter 1 data for 2025 showed a 25% reduction and quarter 2 showed a 21% reduction. However, trust data from April to October 2025 showed that the framework was not embedded in practice. During this six‑month period, there were 206 delays exceeding 24 hours, equating to approximately eight women per week. These delays increased the risk of poor outcomes.

We reviewed multiple concerns received by the CQC which related to induction of labour, including prolonged delays, insufficient information for women, and poor‑quality care, all of which contributed to negative experiences and poorer psychological outcomes.

The service had an observation area (OA) where staff cared for women with complex health needs or recovery after caesarean. We had multiple concerns about the configuration of the OA. Staff did not have a clear line of sight for women who required one-to-one care. There was no monitoring of women who were transferred with an arterial line (a cannula inserted straight into an artery for continuous monitoring and easy access for frequent blood samples to be obtained). There was no centralised monitoring, staffing was not adequate, and not all staff had the right experience to provide post-operative care required for women who had had a Caesarean section. Data showed that between November 2024 and October 2025, the OA was cited in 58 incidents. As a result of our concerns, the trust made improvements to reconfigure the area and enhance staffing skill mix.

Ultrasound scan appointment slots were not always available in a timely manner. Data from the services ‘risk register’ showed there were delays with diagnostic imaging services due to lack of staffing levels.

However, the maternity referral and admission processes ensured that essential information about women was received to determine the correct pregnancy care pathway. Women could self-refer for care using the trust’s electronic referral which was user friendly and explained the process. Although this was not currently available in different languages the maternity Equality, Diversity and Inclusivity team developed a poster that was circulated to all community team hubs, nursery centres, GPs practices and Pharmacies in Oxfordshire to enhance accessibility.

Community midwifery teams cared for women in community settings across the region during the ante and postnatal period and when women requested a home birth. The trust had identified areas in Oxfordshire of social deprivation, and discrete midwifery teams were assigned to facilitate continuity of carer (a model which ensured women received dedicated support from the same midwifery team throughout their pregnancy).

The service had a large maternal and fetal medicine department. Clinicians from other hospitals referred women with complex needs for care. Obstetricians specialised in various aspects of fetal medicine, including congenital abnormalities. Staff told us the service had received national recognition for their maternal medicine care pathways.

The maternity assessment unit (MAU) was a large area designed to treat antenatal referrals from other areas; maternity triage sat within its footprint. Staff followed the trust-wide MAU Guideline. The guideline had exclusion criteria to ensure women with symptoms requiring immediate review were risk assessed on the delivery suite.

There was a dedicated 24-hour triage service located in the Maternity Assessment Unit. Leaders were working with colleagues in the Buckinghamshire, Oxfordshire and Berkshire West (BOB) Integrated Care System (ICS) to introduce a systemwide triage service (MAMA’s Line) that would be hosted centrally by the Ambulance service to provide 24/7 maternity telephone triage for all the service providers within the system network. Experienced midwives answered triage calls and recorded patient details on the electronic patient record. Managers diverted calls to the delivery suite when lines were busy to maintain cover on the triage line.

Staff in triage completed a standardised risk prioritisation tool and leaders monitored compliance. Maternity triage operated as a 24-hour service within the MAU footprint. Two GPs were allocated to the maternity assessment unit and triage area each week on different days and a SAS (speciality, associate and specialist doctor) also provided additional cover. However, triage and MAU were busy, reduced staffing and limited capacity contributed to lengthy delays caused by bed shortages and delays in obstetric reviews.

The antenatal ward cared for pregnant women needing additional treatment. Women received care in line with national guidance. Doctors completed ward rounds and midwives used equipment to monitor fetal and maternal wellbeing.

The service had a clear pathway for planned caesarean section. Women requiring a medical caesarean and women who requested a caesarean were risk assessed by midwives and doctors and provided with information about the risks and benefits.

Theatre staff worked to a high standard and followed national guidelines for completing theatre checklists via the electronic patient record. Anaesthetists attended morning huddles. Anaesthetists ran specialist antenatal clinics for the targeted review women with complex obstetric and psychological needs.

The service had an alongside midwifery-led unit (MLU) called ‘The Spires’ on the hospital’s 7th floor and 4 stand-alone community-based MLUs for women seeking low-risk, low-intervention births. The service used the MLUs to care for women during their antenatal and postnatal care which meant mothers had continuity of care.

Midwives followed an inclusion criterion for the MLUs as part of individualised birth planning to ensure the recommended place of birth was most appropriate for the woman and baby's needs and individual factors. Each unit had a birthing pool, and pool evacuation equipment was available. Midwives followed escalation criteria to transfer women if complications arose.

High-risk women requesting birth in an MLU were risk assessed by a consultant midwife and an obstetrician, who provided advice on risks and benefits. However, records showed that there were times when women could not access ‘The Spires midwifery led unit’ due to staffing or capacity issues.

The postnatal unit included a 7 transitional care beds for women who had babies who needed interventions like antibiotics. A neonatal team and an obstetric team reviewed women and babies on the ward.

Discharge coordinators provided administrative support for midwives to facilitate timely and appropriate discharge from hospital. They made sure key documentation was completed and sent notifications to 3rd party care organisations to inform them women and babies were going home.

The evidence showed a good standard of safeguarding.

The service collaborated with women and families to understand what being safe meant to them as well as with 3rd party care partners on the best way to achieve this. Staff 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 made sure they acted on concerns quickly and appropriately.

Staff received safeguarding training in line with their role. Records showed obstetricians and midwives received level 3 safeguarding training in both adult and children’s safeguarding. Administration staff had completed level 2 safeguarding. Data showed that over 95% of staff had received safeguarding training at the level required for their role. Staff knew how to create a safeguarding alert and acted to safeguard women and babies.

The named midwife and named consultant for safeguarding received level 4 safeguarding training. Three obstetric consultants had a specialist interest in mental health, and the service ran multidisciplinary team (MDT) clinics for women with complex mental health issues which included obstetricians, mental health liaison, perinatal mental health practitioner, and safeguarding teams. The service worked closely with substance misuse agencies.

Staff received Mental Capacity Act (2005), FGM (Female Genital Mutilation) and PREVENT training. PREVENT training is an extension of existing safeguarding duties, alongside efforts to protect people from other harms such as gang involvement or exploitation.

The maternity safeguarding team worked alongside the trust wide safeguarding team and submitted a quarterly safeguarding report to the board. The team consulted external stakeholders including the local authority and social care teams. Staff collaborated with their partners to identify themes and build a robust safeguarding framework. Safeguarding board reports identified emerging themes. For example, homelessness had become a significant issue within the maternity service, increasing the safeguarding risk to women both with and without recourse to public funds. Senior safeguarding leads engaged with local councils and charities to explore solutions.

In Oxford, there were increasing numbers of pregnant women with newborns living in hotel accommodation without cooking facilities. This created risks for nutrition, health, and wellbeing during pregnancy and early parenthood.

The maternity safeguarding team contributed to Oxford City Council’s Emergency Housing Framework, offering an opportunity to influence the delivery of safeguarding and practical advice for families in emergency accommodation.

The trust introduced ‘Safe and Sound’ safeguarding and mental health learning sessions. This represented a positive step in supporting complex case management. The sessions aimed to promote reflection, shared learning, and best practice. This meant midwives were supported with safeguarding cases.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. The service developed ‘tips and tricks’ to help women disclose domestic violence. Staff could access guidance for teenage pregnancy and concealed pregnancy.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Key staff attended complex case reviews with the local authority to discuss children in need. A barrister who reviewed a safeguarding care plan confirmed that midwifery documentation was exemplary, reflecting the commitment of the safeguarding team.

Staff recorded safeguarding alerts on a tab on the electronic patients’ records. Safeguarding teams monitored referrals and made sure that teams had access to clear safeguarding plans.

Staff followed safe procedures for children visiting the service.

Staff received and reviewed national safeguarding alerts, and made sure key areas were aware of complex cases and vulnerable people who may access the service unannounced.

The service had a baby abduction policy, ward areas were locked securely and accessed by a call buzzer for patients. However, during our inspection we were able to tailgate a family when entering the delivery suite. We raised this with staff who took immediate action so that staff answering the buzzer were clear that staff should review people before entering maternity.

The service understood risk but did not always work well to manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them. After the inspection, we raised concerns with service leaders who took action to mitigate the risks.

We found areas where risks were not managed well. Staff used cardiotocographs (CTG) to monitor babies’ heartbeat and wellbeing during labour. A fetal monitoring specialist midwife supported midwives to identify deviations and escalate appropriately. The fetal surveillance midwife completed quarterly CTG documentation audits, data showed a 30% shortfall in one element of CTG reviews.

Also, during the inspection, we found that staff on the delivery suite did not always perform CTG fresh eyes’ (having a 2nd clinician review the CTG results) in line of sight of the patient in line with national guidelines. This meant that staff did not capture a holistic picture of evolving risk. We raised this with leaders who took immediate action to remind staff about the importance of completing the assessment in front of women in labour.

During the inspection, we observed a neonatal emergency and identified unsafe transfer and handover practices. During the emergency we observed that staff did not effectively use the ‘situation, background, assessment and recommendation’ (SBAR) protocol. We fed this back to managers, who reminded staff that they must follow the SBAR process to ensure they communicate vital information. Audit data submitted after the inspection identified opportunities for improvement and implemented monthly monitoring to ensure staff were consistent in their approach to handover.

A thematic review of the Learning from Patient Safety Events (LfPSE) dashboard identified the following reported themes which included but not limited to, postpartum haemorrhage (PPH), maternal readmissions, perineal trauma, administrative and communication failures, and unsafe staffing. The data was reflective of what we found during inspection and helped support CQC monitoring and reporting.

However, staff used a Modified Obstetric Early Warning Score (MEOWS) tool to plot observations to highlight women’s physical condition during labour. Managers monitored compliance. Audit data for September 2025 showed staff had completed MEOWS correctly and escalated concerns when there was a risk of deterioration.

Maternity service leaders reported an increase in referrals linked to complex needs and maternal preference. Staff involved women in decisions about caesarean section. Staff completed holistic reviews for women with previous birth trauma or ‘Tocophobia’ (fear of childbirth), explained risks and benefits and supported emotional wellbeing.

The service made ‘homebirth’ available to women, facilitated by community midwives. Midwives completed holistic risk assessments and arranged additional diagnostic tests when required.

Staff collaborated with obstetricians and the consultant midwife when women with additional health needs chose to give birth outside of guidance and provided additional information about the risks and benefits. Obstetricians recorded maternal requests in care plans and in the maternal patient record.

The service provided perinatal multidisciplinary (MDT) mental health clinics for patients with complex mental health needs and completed initial psychological assessments. Three consultants had a specialist interest in perinatal mental health who collaborated with community perinatal mental health liaison teams.

Staff completed colour-coded newborn risk assessments after birth, including maternal psychological and health history. Babies identified as ‘high risk’ were admitted to transitional care for closer monitoring and support with infant feeding.

The evidence showed some shortfalls. The service did not always maintain and control potential risks in the care environment. They did not always make sure facilities, equipment and technology supported the delivery of safe care.

The John Radcliffe Hospital was built in the 1970s and designed to accommodate a smaller birthing population. Since the 1970’s the female population has grown by 45% and the Women’s Centre which included maternity services was no longer big enough to meet demand. Suggested improvements were not always possible due to the construction of the building and the layout of the building compromised patient pathways due to compliance with fire risk mitigation. Some areas did not meet Department of Health guidance (Health Building Note 09-02). For example, delivery rooms on the delivery suite were not ensuite and could compromise women’s dignity during labour.

The observation area (OA) lacked central monitoring and clear sightlines for staff. The trust installed wall-mounted monitors and pull-down drip stands to save space, but beds remained cramped. Staff said they could create space in emergencies. After we raised concerns, leaders took immediate action and reconfigured the area into three integrated sections to improve visibility and safety. The neonatal unit was nearby for urgent transfers.

Poor Wi-Fi affected centralised CTG monitoring, and leaders had recorded this as a risk.

Reception staff working in the maternity assessment unit did not have a clear line of sight to patients which posed a risk in the event of an emergency. However, following the inspection the service provided evidence that the service removed the screen, allowing clear line of sight from reception to the waiting area.

All areas had suitable childbirth equipment. Emergency trolleys contained medication with breakable seals.

We found some equipment with out-of-date safety check labels. Staff could not explain how they knew equipment was safe. After the inspection, the trust provided a maintenance report confirming evaluation and risk assessment. However, the trusts maintenance report did not include a live asset log to confirm checking met trusts performance requirements. Incorrect and out of date labelling posed a risk to patients and staff.

Learning from Patient Safety Events (LfPSE) data showed staff had reported equipment & infrastructure Issues. These were included but not limited to fridge temperature breaches in drug/milk storage rooms (up to 31. 3°C). Faulty CTG machines, epidural pump failures, missing instruments and lift outages.

Staff followed ligature risk procedures, and cutters were available in all areas. However, not all staff knew where to find them. For example, postnatal ward staff asked the manager for their location, which could delay emergency response.

Leaders completed annual environmental risk assessments for each midwifery-led unit. The Spires midwifery led unit on the seventh floor included delivery rooms with birthing pools. Midwives had training and equipment for pool evacuation.

Matrons and ward managers conducted monthly inspections and reported findings in the Maternity Services Quality Report. These identified areas for improvement, such as portable appliance testing.

Delivery rooms were single occupancy with essential equipment but lacked bathrooms, so women had to share facilities. The delivery suite appeared clinical, with bare walls, stark lighting, and limited space, lacking a homely feel.

Staff had clear access from the delivery suite to three obstetric theatres and recovery. The Butterfly bereavement suite was on the seventh floor and included three rooms for postnatal care after pregnancy loss.

We inspected two standalone midwifery-led units at Wallingford and Chipping Norton. Some of the rooms were small but they had the equipment needed. Leaders completed annual checks, and equipment met national guidance. Birth rooms had pools and evacuation equipment. Staff received training on how to evacuate women from the pool in the event of an emergency. However, in the Wallingford Maternity & Birthing Centre, there was no signage to indicate the storage of hazardous substances.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work well together to provide safe care that met people’s individual needs.

Service leaders did not always deploy the right staff to key areas although there were enough staff, who received effective support, supervision and development most of the time. However, staff worked together well to provide safe care to meet people’s individual needs.

This was a large, busy tertiary maternity unit. The trust had seen an increase in complex cases, making acuity challenging and unpredictable. National data shows September and October were the busiest months, and our inspection took place during this peak period in October 2025.

Staff reported shortages throughout the service. However, not all staff reported it as an incident. Clinical staff told us they were often required to support clerical duties due to lack of administrative staff.

A CQC analysis of Learning from Patient Safety Events data from November 2024 to October 2025 showed that unsafe staffing levels were reported across wards and by community midwives who were reallocated from community areas to support clinical staffing on the unit in accordance with service processes. Also, lack of staff meant that women suffering bereavement were not always cared for in appropriate areas. Staff also reported missed breaks which negatively affected staff wellbeing. Following the inspection leaders acted upon our feedback and made sure bereaved women were cared for in the appropriate setting. Staffing numbers and skill mix on the observation area (OA) enhanced care unit did not meet the needs of the women. The planned staffing of the unit was 2 adult nurses, 2 midwives and a midwifery support worker (MSW) to look after up to 10 women/birthing people and their babies. There were not enough adult nurses with post operative care experience to ensure that women who had had a Caesarean section received post-surgery recovery care. We raised concerns with leaders who advised that they had completed a review of theatre staffing with a focus on strengthening staffing in the recovery process. As a result of our feedback, they immediately expedited the implementation of additional recovery nurses.

Staffing levels were not always sufficient to manage the volume of women who required induction of labour. The maternity service biannual maternity safe staffing report (Quarter 3 and 4 2024-2025) lacked clarity because it did not clearly show a breakdown of each area and how staffing was planned for that area. The impact of this is that staffing data was complex and did not provide assurance that actual staffing for induction and other aspects of care met the needs of women and families.

Community staff raised concerns about the on-call system because there were times when they were called to work a 12-hour night shift after working a day shift. Managers redeployed community staff to backfill hospital shifts overnight during busy periods. Which resulted in extended periods without rest. Staff told us this meant they were awake for more than 24 hours, which they felt impacted their wellbeing and patient safety. This posed a risk as evidence shows that fatigue can cause mistakes that lead to harm. Following our inspection feedback the trust provided assurance that community midwives called to cover the unit should only be called for a 4-hour period and if the shift occurs after midnight the midwife is entitled to a compensatory rest period the following day.

However, midwifery leads completed a biannual workforce planning tool update, which calculated the number and grade of nurses and healthcare assistants required. In October 2024, records confirmed the current midwifery staffing level was 332.06 whole time equivalent (WTE). Service leaders recognised the increase in the complexity of patients and made improvements to the birth to midwife ratio and increased this to 1:23, which exceeded the national average of 1:28.

Leader’s ‘RAG’ (red, amber, green) rated actual midwifery staffing levels, where green signified appropriate staffing levels. Data from October 2024 to March 2025 showed actual staffing levels were in amber status most of the time which meant actual staffing did not match planned staffing levels.

Managers reviewed staffing acuity on a regular basis and escalated concerns to a midwifery coordinator. Ward managers adjusted staffing levels daily to take account of case mix. Red flag staffing events data for ‘in patient areas’ showed that staff were frequently moved between specialty areas.

There was a designated band 7 supernumerary midwife coordinator on the delivery suite for most of the time. Red flag data for the reporting period showed 11 occasions between November 2024 to October 2025 when the supernumerary coordinator covered other midwifery tasks which took the focus off their helicopter view of intrapartum care delivery.

A senior midwife staffing ‘bleep holder’ oversaw staffing and capacity issues over a 12-hour period to ensure a helicopter view of capacity, acuity, care, and performance. They carried a pager so that they could be contacted at any time whilst on duty throughout the hospital. During our inspection, the bleep holder was busy trying to reduce operational pressure on women and services. However, there was no staffing bleep holder at night therefore, a second night shift band 7 midwife managed the bleep during night shifts and was available to staff working across the unit.

At the time of the inspection, there were a high number of staff on maternity leave. To mitigate the shortfall, the service had over recruited staff. Practice educators supported new staff with a consistent orientation and induction model. However, staffing improvements throughout the maternity service were not fully embedded. Staff often felt overwhelmed during peak times.

Staff were qualified and had the right skills and knowledge to meet the needs of the patient group. Specialist midwives made up 10.5% of the total midwifery workforce in line with the national staffing tools. However, staffing did not reflect the skill mix. Due to the successful midwifery recruitment meant the workforce included a considerable number of junior midwives.

Leaders had added a twilight midwife to the maternity assessment unit (MAU) roster but delays in obstetric reviews and admission backlogs meant demand still exceeded capacity. There was no designated registrar working in the triage area. On the day of the inspection the area was very busy; one woman left the unit before they were seen. After the inspection we raised concerns about medical staffing in triage and the maternity assessment area. Leaders told us that baseline medical daytime staffing for MAU included an SHO who may or may not be training in Obstetrics and Gynaecology (O+G) and an additional doctor who had experience in O+G or GP with a specialist interest. Out of hours from 6-7pm until 8am in the morning there was no dedicated staffing.

When necessary, managers deployed bank nursing staff to maintain safe staffing levels. The backfill rate reflected cover for sickness, annual and maternity leave. Data for November 2024 to October 2025 for use of bank and agency in the women’s centre alone equated to an average of 10.2 WTE posts per week.

Data showed that the number of support staff such as receptionists and support staff varied through the month. The impact of low support staff numbers meant clinical staff performed administrative duties which reduced the time they spent caring for women.

Managers identified staff learning needs and monitored training compliance. Staff were up to date with obstetric mandatory training. Compliance for maternity training was over 95% for fetal monitoring, emergency training, and the skills and drills trolley programme delivered in the clinical environment.

Staff completed 18 trust-wide core skills modules in addition to obstetric training. Compliance exceeded the trust standard of 85%, with over 90% of staff completing at least 16 of the 18 modules.

Managers provided new staff with appropriate induction.

There were 23.14 consultants (25 people) working for the service across all specialties. The service employed a further 18 WTE registrars and 17 senior house officers (SHO).

Consultants followed their job plans to manage their planned activity for the week. The clinical manager followed the Job Planning Policy, which included reviews of programmed activities and set out consultants’ duties and responsibilities. Job plans were reviewed annually to ensure oversight of activity and acuity.

There were adequate 24-hour obstetric cover and 16 consultants contributed to the on-call rota. Registrars worked 1:9 on-calls a month and SHO’s worked 1:17 on-calls. Consultant onsite cover was available 8am until 8pm, with off-site cover and secure access to patient information out of hours.

Obstetric managers used bank to backfill gaps in the roster. Data showed the use of bank was minimal. The service did not use locum doctors to cover shifts.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

During inspection we found hazard tape was applied to the resuscitaires which is a piece of emergency equipment used to treat newborn babies. The hazard tape was put there in 2023 to alert staff to some oxygen‑pressure issues. The British Association of Perinatal Medicine (2023) issued a safety alert that advised a local review of this equipment. To mitigate the risk the service added an extra neo‑puff because the equipment was essential and costly. Leaders planned a task‑and‑finish group to establish a long‑term solution. However, the tape had been part of the equipment for 2 years. The use of hazard or adhesive tape on clinical equipment creates an infection‑control risk, as it cannot be effectively decontaminated. The safe IPC standards state equipment must remain fully cleanable, and any tape should only be used on a single‑patient basis where clinically necessary.

Staff maintained equipment and kept it clean in most areas. However, we found a dusty resuscitation trolley on the antenatal ward, stored away from the main area and dust behind trolleys on the ward

Staff used clinical grade equipment wipes to clean equipment after use and ‘single use’ items were available when providing personal care.

Most ward areas were visibly clean, had required furnishings and housekeeping staff followed a cleaning schedule. Staff managed clinical waste well. We saw that bins were colour coded to separate clinical and domestic waste. Staff used yellow ‘sharps’ bins.

Curtains on bays were labelled with the date they had been changed and records confirmed this.

Cleaning records were not visible in all areas, because housekeeping staff recorded cleaning on a digital app. The records were up to date and demonstrated that the ward areas were cleaned regularly. Where cleaning audits identified shortfalls, these were addressed immediately with action plans to make improvements.

Staff adhered to infection control principles, including handwashing and hand sanitiser was available in all areas. Records confirmed that hand hygiene audits were completed monthly in all areas and compliance rates were over 98% for the period November 2024 to October 2025.

The service did not always make sure that medicines including medical gases and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

At the previous inspection, we identified concerns regarding staff adherence to trust policies for medicines records and storage. Although leaders had made improvements we found other areas of concern.

We remained concerned about the limited clinical pharmacy service in maternity, which restricted risk-based support for high-risk pregnancies, medicines reconciliation, and safe medicines use post-partum. Maternity leaders had recognised this as a risk and added this to their current risk register in December 2021.

Maternity incident data showed reported errors in missed doses of medication and lost or mislabelled blood samples which confirmed that current procedures were not always safe.

Staff explained the challenges of operating dual records across the trust’s care record system and the dedicated maternity system.

Leaders did not implement the right equipment to ensure that staff stored medical gas cylinders safely. We observed unsecured medical gases or medical gases in the wrong type of holders which could pose a risk of fire. We also had concerns that a nebuliser had not been serviced.

However, maternity staff stored medicines, including controlled drugs safely. Service leaders confirmed staff stored medication within recommended temperature ranges.

Emergency medicines boxes prepared centrally were available, tamper-evident, and in date. Locally prepared boxes were also available to support deteriorating patients. However, there was a lack of consistency, resulting in variation in content, labelling, and checking processes.

Over-labelled medicines were available for discharge prescriptions, but labelling quality was variable, creating a risk of incomplete directions for patients on discharge.

Processes were in place to monitor staff exposure to nitrous oxide, and records for controlled drugs and stationery complied with trust guidance. Midwives were authorised to supply medicines under exemptions and patient group directions (a written legal framework allowing registered healthcare professional to supply or administer prescription-only medicines to a pre-defined group of patients without a prescription) in line with legislation and trust policy.