St Peter's Hospital

Updated 5 December 2025

Date of assessment: 11 to 12 March 2025. Ashford and St Peters Hospitals NHS Foundation Trust provides a range of NHS hospital services. This assessment looked at maternity services following a section 29a Warning Notice in January 2023.

The maternity service was previously rated inadequate. The rating from maternity has been combined with ratings of the other services from the last inspections. See our previous reports to get a full picture of all other services at Ashford and St Peters Hospitals NHS Foundation Trust.

The St. Peter’s Hospital location assessment has not changed and continues to be rated as ‘requires improvement’.

Updated 4 December 2025

Date of assessment: 11 to 12 March 2025. This was a follow-up assessment following a section 29a Warning Notice in January 2023. We undertook an on-site visit, completed virtual interviews and reviewed data provided by the trust.

St Peters Hospital is in Chertsey, Surrey, and is operated by Ashford and St Peter’s Hospitals NHS Foundation Trust.

Maternity services offered midwifery-led care and obstetric care during the antenatal, intrapartum, postnatal and community care.

Services included antenatal clinics, maternity day assessment unit, and the Abbey Birth Centre located on the first floor. The antenatal and postnatal Joan Booker Ward on the 2nd floor and maternity triage, the obstetric-led labour ward, the bereavement suite and maternity theatres were located on the 4th floor.

Elective caesarean sections at this time continued to be completed in the main theatres within the main hospital.

There had been 2,703 births at this service in the last 12 months. With 9.3% of those women and birthing people choosing to give birth in the Abbey Birth Centre, 0.7% giving birth at home and 0.6% giving birth before arrival to hospital.

Data provided by the trust showed, around 18% of local pregnant women and birthing people lived within the top quarter for poverty. With 20% of women and birthing people being from a black, Asian and ethnic minority background and 19% of women did not have English as their first language.

We found improvements during the recent assessment and the trust had mostly met their Section 29a Warning Notice requirements.

We assessed 30 quality statements across the safe, effective, caring, responsive and well-led key questions. Scores from the assessment were combined with ratings and scores from previous inspections to give the rating.

There was a good safety culture where events were investigated, and learning was embedded to promote good practice. Staff provided safe care and treatment, the environment was safe and mostly well maintained. The maternity service had core staff within the day assessment and triage. To ensure staffing levels met the needs of women and birthing people, leaders had introduced assigning staff to their designated maternity area at the start of each shift. Staff delivered good care and treatment following evidence-based practice and women and birthing people had good outcomes. Staff were kind, caring and compassionate. Women and birthing people could access care and treatment when they needed it. The department and staff were well-led by strong leaders who embodied the cultures and values of their workforce. There was improved governance, risk management and culture.

The service was in breach of the legal regulation within safe care and treatment in regard to completing daily checks of emergency equipment.

Updated 5 March 2024

We conducted a responsive, focussed assessment of the medical division at St Peter’s Hospital commencing on 20 March 2024, due to receiving information of concern related to the delivery of patient care. We assessed a limited number of quality statements from all 5 key questions and found areas of good practice and some concerns. The care we observed was safe and patients were positive about their experiences. However, we found breaches of the regulations for safe care and treatment. Planned versus actual nursing staffing did not always match, due to short notice sickness absence. Patient records showed unwitnessed falls and medicine errors that could be attributed to low nurse staffing and skill mix, along with reported lapses in personal care such as nutrition and promoting mobility. There was a delay in informing the trust of the breaches and we have asked the trust for an action plan.While the division had established governance processes appropriate for their service, staff expressed concerns of a lack of an open safety culture within the trust and told us safety was not always a top priority. There was a new executive leadership team in place at the time of our visit. Some staff said they did not feel confident to raise concerns and felt this was adversely affecting the work of the division. A number of senior staff expressed worry about a lack of a clear vision and organisational strategy to guide priorities. Senior trust leadership had recognised these problems, and the trust chairperson had asked for an independent review shortly before our assessment visit. We saw evidence of initial actions undertaken by the executive team in response to the report recommendations. The scores for our assessment have been combined with scores based on the key question ratings from the last inspection. Though the assessment of these quality statements indicated some areas of concern, our overall rating remains good. Our assessment was significantly delayed due to technical and other issues related to changes within the CQC. We acknowledge that during this time planned interventions and improvements in governance was progressed by the trust.

Updated 4 October 2018

Our rating of this service improved. We rated it as good because:

• Staff fully understood how to protect patients from abuse and the service worked well with other agencies to do so. The safeguarding team were visible on the children’s wards both days of our inspection and staff told us they came to the wards every morning to assist with any safeguarding issues.
• Risks to people who used the services were assessed, monitored and managed on a day-to- day basis. We saw comprehensive risk assessments carried out on admission. This included background information on the child’s previous admissions and if they were known to social services or under any protection plan.
• Although medical staffing was on the risk register, the division were maintaining safe staffing levels. Nurse staffing levels were often achieved by using bank and agency nurses. However, the department had a robust induction and competencies check and tried where ever possible to use regular agency to mitigate the risk.
• The service used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. The service used information to improve the service. The department also had a separate children and young people specific safety thermometer.
• Pain assessments on children and young people had greatly improved, with pain assessment forming part of the paediatric early warning systems (PEWS) chart.
• The service monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.
• Staff involved patients and those close to them in decisions about their care and treatment.
• The play therapy team were available seven days a week. They came to the wards to work with patients around anxiety and distress, and helped to prepare them for procedures.
• Patients’ needs were considered at all stages of paediatric care. There had been a marked improvement to the care of children or adolescents suffering with mental ill health since our last inspection.
• People could access the service when they needed it. There were good links with local GPs who could call the paediatric registrar (who held a bleep) for telephone advice, or could directly contact the consultant in charge. The service has helped to reduce referral to hospital and improved patient experience.
• Staff universally felt supported by their managers and each other. We saw a collaborative team who worked together to ensure they were delivering the best care to their patients.
• The senior staff we spoke to understood the challenges and could identify what changes were needed to address them. An example of this is the planned paediatric assessment unit to help with the flow and staffing of the department.

However:

• We found chipped skirting boards and peeling paint in bathrooms, this could be an infection control risk as these areas could not be cleaned effectively. We also found some light dust in high areas, such as above beds, and on television brackets, suggesting these areas may need to be cleaned more often.
• We found an un-locked sluice which contained cleaning products and waste in the incorrect bin. This could mean patients could access the harmful cleaning products.
• The department did not have a dedicated pharmacist. The ward was visited each day by a pharmacist or pharmacy technician. However, we found for one ward had not been visited by a pharmacist for over two days to clinically check the medicine charts or carry out medicines reconciliation.
• Some leaflets needed to be reviewed to ensure they contained up-to-date information.

There was no formal care passport for patients with complex needs. This was not in line with recently recommended National Confidential Enquiry into Patient Outcomes.

Updated 4 October 2018

Our rating of this service improved. We rated it as good because:

• Following our inspection in 2014, there had been improvements to the critical care unit. These improvements contributed to the safety of patients.
• There were effective systems in place to protect patients from harm and a good incident reporting culture.
• The critical care outreach team provided effective support to the general wards with the management of deteriorating patients and preventing admissions to ICU.
• Patients received effective, evidence-based care and patient outcomes were within the expected range. There was an extensive audit and research programme and an investment in finding new ways to improve patient outcomes.
• Appropriately qualified staff cared for patients. There were effective training programmes for both nursing and medical staff. The percentage of nursing staff with post registration qualification in critical care met the recommended guidelines.
• There was a strong culture of multidisciplinary working on the unit.
• There was an embedded culture of supporting patients and their families during and after admission to critical care. The service was committed to engaging with patients and their relatives and tailored care to suit individual needs.

Updated 10 March 2015

The specialist palliative care team were accessible, visible and supportive of all areas in the trust. Team working with all wards and departments was evident to promote safe and effective end of life care. Staff throughout the trust valued the skills and support of the specialist palliative care team. The review of patients took place within multidisciplinary meetings to promote coordinated, safe and effective care. Care records demonstrated that potential problems for patients were identified and planned for in advance. The team were piloting and reviewing a person-centred care plan to be used to improve the safe and effective delivery of care in line with current best practice.

Staff throughout the trust were caring and treated end of life patients and their relatives with dignity and respect. Staff made every possible effort to ensure that patients and relatives had everything they needed to be comfortable and accommodated. The close working relationship between the nursing and medical staff, chaplaincy, bereavement, mortuary services and porter services was evident to support patients and relatives.

Updated 10 March 2015

We found that a safe environment for patients was maintained and that the required safety checks were being completed and recorded. The outpatient waiting areas and clinic rooms were clean and hygienic.

Patients attending the outpatient clinics were positive about their treatments and consultations and the professionalism of the staff.

Clinical staff were caring and compassionate in their approach to patients. Staff were treated with respect.

The trust was taking action and implementing changes to respond to an increased demand in some clinic services. Some additional clinics were being run and action was being taken to improve the patient experience with regards to appointment booking.

There were consistent processes to monitor the performance of the different clinic services and identify risks and ongoing concerns. There was an ongoing transformation plan for the outpatient service that was being implemented with the engagement of staff.

Updated 27 January 2022

Updated 4 October 2018

Our rating of this service went down. We rated it as requires improvement because:

• The service did not always control infection risks well as there were ineffective systems in place to protect patients from cross infection. Staff did not clean their hands at the right time, did not wear personal protective equipment, such as gloves and aprons, correctly, or manage linen in line with policy. There was a lack of adequate isolation facilities within the emergency department. Waste was not segregated in line with guidance. We found inappropriate items in all of the different waste containers
• The service had suitable premises and equipment but did not a look after them well. Equipment used in the event of an emergency was not checked consistently to ensure it was present, and in working order. Fire exits were blocked; fire doors were not fit for purpose, and would be ineffective at protecting patients and staff from fire and smoke.
• Staff did not always keep appropriate records of patients’ care and treatment. Casualty care records we looked at varied in quality and completeness. We found two set of notes where we could not read the writing.
• The service provided mandatory training in key skills but not everyone completed it. Mandatory training was below the trust target of 90%, for all staff groups.
• The service monitored the effectiveness of care and treatment and used the findings to improve them. The department took part in both national and local auditing. However local audits did not reflect, or limited improvements were seen despite non-compliances being identified.
• Patient indefinable information was not kept secure. Patients’ information including full name, date of birth and other information was on display to other patients and visitors to the department.
• Staff did not always give patients food and drink to meet their needs and improve their health. Patients were not routinely offered a choice of food to meet both dietary and cultural requirements. This meant, that patients with dietary requirements or choices, such as lactose intolerance or being a vegetarian were not offered a choice of food.
• Pain was manged well, but the assessment and recording of patient’s level of pain on arrival at the emergency department was variable. Waiting times from treatment and arrangements to admit, treat and discharge patients were not in line with good practice. The service did not meet the Department of Health’s standard for emergency departments, which is that 95% of patients should be admitted, transferred, or discharged within four hours of arrival in the emergency department The service did not meet the Royal College of Emergency Medicine recommends that the time patients should wait from time of arrival in the department to receiving treatment should be no more than one hour.

However:

• Equipment was visibly clean and had been checked for electrical safety. There was a programme of planned preventative maintenance
• The service managed patient safety incidents well. Risk was managed and incidents were reported and acted upon with feedback and learning provided to staff. There were effective systems in place to report incidents. Incidents were monitored and reviewed and staff gave examples of learning from incidents. Staff understood the principles of Duty of Candour regulations and were confident in applying the practical elements of the legislation
• The service provided care and treatment based on national guidance and evidence of its effectiveness Staff had access to up to date evidenced based guidance from organisations such as the National Institute for Health and Care Excellence and the Royal College of Emergency Medicine. There was effective multidisciplinary team working within the service and with other agencies. The service also participated in national audits.
• Staff knew the trust’s vision and strategy, and told us how they made sure they put these into their practice.
• Patients were treated with dignity and respect. Staff introduced themselves to patients and asked what they would like to be called.
• Staff involved patients and those close to them in decisions about their care and treatment. Patients confirmed that they felt involved in decision-making and medical and nursing staff shared enough information to support their decision-making; we observed that staff asked if what they said had been understood by the patient and if there were further questions the patients, relatives or carers had.