St Peter's Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Staff assessed people, so the care and treatment provided mostly met their needs. This included both their mental and physical health and any personal circumstances that needed to be considered.

Staff prioritised women and birthing people, where safe to do so to have the birthing experience they wanted. We observed active discussions around women and birthing people with complex care who required support to have the birthing experience they wanted, and teams worked with other agencies to develop a multi-agency birth plan.

Staff worked in a culture of evidence-based practice. Staff worked together and with others when assessing people’s needs and shared information to maintain continuity of care.

The effective key question was not rated in the last assessment. During this assessment we rated 4 quality statements and rated the service as ‘Good’.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, well-being and communication needs with them.

The service used an electronic system to identify women and birthing people with additional needs such as safeguarding concerns, mental health needs and complex care.

The trust had improved translation services since our previous assessment. Teams used a telephone language line, and a video language line was launched in November 2024. To maintain assurance of staff compliance in supporting women and birthing people with translation services, an annual audit of language line was completed.

The trust had introduced specific technology which translated information leaflets into a specific language as required.

As part of the daily situational, background, assessment and recommendation (SBAR) handover staff reviewed any language barriers for women and birthing people so they could be supported.

The service completed a maternity equality data report. We reviewed the latest report from January 2025. The report showed a breakdown of ethnic and multi deprivational groups within key maternity targets for example, 3rd and 4th degree tears and post-partum haemorrhage.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. Staff did this in line with legislation and current evidence-based good practice and standards.

Staff prioritised women and birthing people’s needs and supported where safe, women and birthing people to have the birthing experience they wanted.

During midwifery safety huddles we observed active discussions around women and birthing people with complex care who required support to have the birthing experience they wanted. The service had worked with other agencies to develop a multi-agency birth plan.

Staff told us that daily huddles and multi-disciplinary handovers were held to support safe transition of care between teams during shift changes. Potential and planned discharges were also supported through daily meetings with referrals made prior to discharge.

Staff followed up-to-date policies to plan and delivered maternity care according to evidence-based practice and national guidance. We reviewed a sample of maternity policies and found these were in date and referenced appropriate guidance. The service had 2 fail safe officers to provide assurance that ongoing assessments and guidance were implemented, with weekly and monthly fail safe reports completed.

People told us that they were satisfied with the care they received, and the team followed birth plans where possible.

The service worked well across teams and services to support people. Staff made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Daily huddles and multi-disciplinary handovers were held to support safe transition of care between teams during shift changes. Potential and planned discharges were also supported through daily meetings with referrals made prior to discharge.

Staff told us how they could access specialist midwives to support women they cared for and improve outcomes.

The service had a multidisciplinary team (MDT) safety summit meeting where learning was shared online and during theme of the week within clinical areas. The annual MDT training agenda included risk assessments and personalised care planning. Clinical and operational guidance included guidance on the roles and responsibilities for escalation.

The maternity service worked closely across the Local Maternity and Neonatal Systems (LMNS). The service had an improvement trajectory which was presented to the LMNS and quarterly assurance visits.

A complex care team worked with the local women’s prison to support women and birthing people to receive the right care and birth choices within a detained setting. The women, birthing people and their families were supported by the team and maternity staff to have access to personalised care during all stages of their pregnancy, labour and birth.

The service supported women and birthing people to manage their health and wellbeing to maximise their independence, choice and control. The service supported women and birthing people to live healthier lives and where possible, reduce their future needs for care and support.

Women and birthing people were supported to initiate breast feeding postnatally in hospital and when discharged home. The service had developed an online platform with feeding and nurturing information leaflets. This was a QR code for both staff and parents to provide information on antenatal conversations on nutritional impartial advice. For example, hand expression and breast feeding. There were information boards, information and literature for women, birthing people and their families to promote a healthier lifestyle.

Staff assessed people's health when admitted and provided support for any individual needs to live a healthier lifestyle. Women and birthing people were asked about their smoking status at their booking appointment and had carbon monoxide monitoring if they smoked. Women were offered smoking cessation support and could be referred to a smoking cessation service.

The service did not always routinely monitor people’s care and treatment to continuously improve it. Staff did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

The service did not always meet clinical expectations. Issues with the methodology to measure fetal monitoring were escalated and addressed through the Saving Babies Lives Oversight Group with input from the Local Maternity and Neonatal Systems (LMNS). However, the service continued not to meet the trust target for fetal monitoring and fresh eyes monthly audits.

Saving babies lives, fetal monitoring and fresh eyes audits were not on the maternity service annual audit plan. The annual audit plan identified the frequency of reporting maternity audits, and which governance forum audits were reported into.

The service monitored assurances and outcomes against the Section 29A Warning notice and breaches identified during the previous assessment via a self-assessment process to evaluate performance.

Performance and audit results were reviewed by senior leads within the maternity areas. We were told results were shared with staff through learning and updates.

The service had reported no adverse incidents within triage since our last assessment. The quality and safety lead chaired the weekly safety summit where the key performance indicators were reviewed, this included a review of frequent attenders to maternity triage.

There was a designated midwife who reviewed feedback and experiences from women and birthing people who had used the service. This information collected was fed back to staff during improvement huddles. Women and birthing people who used the service generally experienced positive outcomes, meeting expectations set out in legislation, standards, and evidence-based clinical guidance. Effective approaches were in place to monitor and improve care, treatment, and outcomes.

Key performance indicators were incorporated into the maternity dashboard for monitoring and oversight. The trust maternity dashboard identified that outcomes were not always within the identified target. For example, the service had a higher percentage of 3/4 degree tears and post-partum haemorrhage (PPH) above 1500mls in assisted vaginal deliveries.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

All women and birthing people we spoke with felt they had been given enough information, including risks and benefits, to make an informed decision about their care and treatment and that they were able to give informed consent.

Midwives understood how to assess women’s and birthing people’s capacity to make decisions.

On our review of women’s and birthing people’s records we found completed consent forms for caesarean sections as well as when gaining verbal consent when completing care.

There were up-to-date policies and procedures, which were accessible to staff through the trust’s intranet site.