St Peter's 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

Since our last assessment, we found leaders had taken steps to improve the reporting, monitoring and managing of incidents. There were effective systems to investigate incidents, identify learning and incidents were reviewed daily and involved a collaborative approach. We found there was an improvement since our last assessment in relation to closing incidents and incidents were closed within required timeframes.

There had been significant improvements within maternity triage. There was an increase in the number of staff during each shift with the service introducing core teams within the day assessment unit and triage areas. There was a dedicated registrar based within perinatal care to cover the day assessment unit and triage areas to support women and birthing people being assessed within specific timeframes.

Maternity triage audits showed the service was consistently above the 90% target for women and birthing people being triaged within 15 minutes. Medical staff told us they had seen a significant improvement with the timeframes of reviewing risk and escalating concerns within maternity triage.

However, we found staff checks on emergency equipment was not always complete. Data showed not all equipment was checked and quality spot checks were not being consistently undertaken on the labour ward.

The service was previously in breach of the legal regulation in relation to safe care and treatment. Although some improvements were found at this assessment, the service remained in breach of this regulation.

At our last assessment, we rated this key question inadequate. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was a 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 service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Since our last assessment in 2023, leaders had taken steps to improve the reporting, monitoring and managing of incidents. There had previously been a significant backlog of outstanding incidents which meant there had been delays in identifying themes and trends and closing incidents within national timeframes.

There was an improved culture of safety and learning. There was now a clear system put into place to investigate incidents and to identify learning, using the model Patient Safety Incident Response Framework (PSIRF) and a Perinatal Quality, Safety Risk (QSR) Framework. Incidents were reviewed daily and involved a collaborative approach, between the risk and governance team and management team, to review incident content and grading. Incidents requiring immediate attention were investigated as a priority, to ensure potential safety concerns were addressed and mitigated. Staff told us they felt confident to report incidents and were supported to proactively identify and manage risks before safety events occurred.

The service had introduced a monthly PSIRF learning forum and a weekly safety multidisciplinary team summit meeting and shared themes on learning with teams in clinical areas during ‘theme of the week’ discussions.

We found that there was an improvement in closing incidents within the required timeframes. The service had 31 open incidents over 60 days, 5 of those incidents were cases being reviewed by the Maternity and Newborn Safety Incidents (MNSI). This had improved from our last inspection.

Women were positive about the care they received. We spoke with the patient safety midwife who told the team that complaints had improved since partners were able to stay overnight to support women and birthing partners. There had been no complaints within the last 6 months within Joan Booker Ward.

Staff were kind and respectful to each other but most staff we spoke with said the service had been through numerous leadership and service changes. Staff told us they felt tired and burnt out and did not feel information regarding changes within the service were always communicated well.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people moved between different services.

Following our previous inspection, the service had made improvements within the Day Assessment and Triage units, with the service introducing core teams within both areas. There was an increase in the number of staff during each shift and a dedicated registrar based within perinatal care to cover these areas to support with women and birthing people being assessed within specific timeframes.

All women and birthing people were assessed by a midwife using a situation, background, assessment, recommendation (SBAR) tool. Women and birthing people within Joan Booker Ward had a daily bedside handover using the SBAR approach.

The service had completed an SBAR audit following incidents relating to inaccurate handovers, which meant an impact on care. The audit found that 100% of SBAR’s had been completed on mothers and babies transferred to the postnatal ward.

Women and birthing people attended the day assessment unit for both scheduled and unscheduled care. The service completed monthly audits to determine how long women and birthing people waited for further assessment and if required, a medical review.

The service used a nationally recognised risk review tool within maternity triage. There were clear guidelines for using the risk review tool and staff compliance of key performance indicators was monitored via an electronic dashboard. Leaders reviewed weekly compliance reports including key performance indicators at the weekly safety summit.

Maternity triage audits showed the service was consistently above the 90% target for women being triaged within 15 minutes. Medical staff told us they had seen a significant improvement with the timeframes of reviewing risk and escalating concerns within maternity triage. Staff felt there was a better oversight of risk and women were mostly seen within specific timeframes.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. 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. The service shared concerns quickly and appropriately. However, not all staff had completed their safeguarding training.

The service had a clear Maternity Safeguarding Policy which was to be used in conjunction with the trust’s Safeguarding Children’s Policy.

Staff understood and could describe how to protect women and birthing people from abuse and gave examples which demonstrated their safeguarding understanding.

Staff received training on how to recognise and report abuse, and they knew how to apply it. However, not all staff had completed safeguarding training. Training records showed both midwifery and obstetric staff did not meet the trust target of 90% for all safeguarding training. There were 86.5% of midwives and registered nurses and 80% of doctors who had completed level 3 adult safeguarding training. There were 90% of midwifery and registered nurses and 83% of doctors who had completed level 3 children’s safeguarding training.

Staff understood the importance of supporting equality and diversity and ensuring care and treatment was provided in accordance with the Equality Act 2010.

Women and birthing people were asked safeguarding questions during each antenatal contact, and we saw evidence of this within their maternity health records.

There were safeguarding alerts added to the electronic records with a clear summary regarding safeguarding concerns.

A multidisciplinary maternity safeguarding meeting took place monthly and included community maternity leaders, the neonatal team, the perinatal complex care team and health visiting leads.

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

The service as part of the local maternity and neonatal systems (LMNS) adopts a central triage telephone (Call a Midwife) line. The midwives answering the telephone triage line worked independently of the maternity service and would triage and signpost women and birthing people to attend if required.

The service conducted a quarterly audit of calls received in the hospital triage line. Staff working in maternity triage did not always complete documentation to show actions taken when women and birthing people called into the maternity triage. The maternity triage team audited every three calls within 24 hours, and data showed there was only 62% compliance with appropriate documentation. Service leaders reported that they recognised the need for improvements.

The CQC assurance action plan on breaches found during the last inspection stated that the Local telephone triage audit would be added to the quarterly triage audit report for ongoing monitoring of compliance. The local service quarterly audit reviews every three calls within 24 hours.

The LMNS quarterly audit audited every 3 calls within 24 hours and data showed the there was only 62% compliance around appropriate documentation completed. Service leaders reported they had recognised improvements were needed.

The CQC assurance action plan on breaches found during the last inspection stated the LMNS telephone triage audit would be added to the quarterly triage audit report for ongoing monitoring of compliance. The service quarterly audit audited every 3 calls within 24 hours.

During our assessment, we did not get full assurance that Cardiotocography (CTG) and ‘fresh eyes’ monitoring was completed within the required hourly timeframes for women who required regular monitoring in labour. ‘Fresh eyes’ monitoring is national guidance, which recommends the CTG trace is assessed by a second midwife or a doctor regularly, to reduce the risk of error when reading the CTG.

There was a discrepancy in the methodology used to measure compliance and this did not provide assurance CTG monitoring was always completed in line with national guidance. This was an issue known to the service and being addressed with the LMNS to ensure standardised reporting methodology between the trusts across the LMNS.

This meant that the electronic system generated low compliance for ongoing CTG monitoring for women and birthing partners. A local paper audit was completed due to the electronic data concerns, which showed a significant improvement in compliance. The compliance was 61.6% for January 2025, however, the service still did not meet the compliance rate of 80% for ‘fresh eyes’ monitoring.

However, during our assessment we saw fresh eyes monitoring was being completed and in the review of women and birthing peoples records all women who were being monitored had fresh eyes completed within the required timeframes.

During our previous assessment there was a lack of reviewing risks through reviewing CTG’s and fresh eyes which meant there had been delays in recognition and escalation of abnormal CTG’s which led to babies being transferred to the neonatal intensive care unit. Although data suggested compliance with ‘fresh eyes’ monitoring was not consistently met during this assessment, we found there were no specific incidents relating to neonatal intensive care unit, an improvement since our last inspection.

To encourage and remind midwives to complete fresh eyes the service introduced ‘Fresh Eyes’ information on each labour room door and had introduced a buddy system for each shift to support with on-time completion.

Midwifery staff did not always escalate when observations identified a potential deterioration in women and birthing people to ensure a timely medical review. The Maternity Early Obstetric Warning Score (MEOWS) was completed by maternity staff for monitoring of deterioration in health. MEOWS audits showed there had been improvements in the completion of MEOWS observations with 100% compliance between October 2024 to December 2024. However, there were continued delays in escalation with only 40% of cases being escalated to a shift lead or ward lead and 63% being escalated for an obstetric review. The audit did provide assurance on overall care and actions taken in response to MEOWS and demonstrated 90% compliance.

Within the last 6 months the service had 3 cases of women and birthing people with sepsis or hospital acquired infections. The theme within all 3 cases was the lack of early identification of symptoms. During our previous assessment, the feedback to the service was to improve staff compliance in accurately following the Sepsis 6 care bundle when women and birthing people presented with symptoms. There was ongoing work to review sepsis and deterioration within maternity service. There was a local multidisciplinary working group completing a thematic review with the trusts Deteriorating Patient Working Group.

Women and birthing people were assessed by a trained midwife who used a standardised triage situational, background, assessment and recommendation (SBAR) tool to identify risk. Staff and leaders told us there were several risk assessment processes for women during their antenatal, intrapartum and postnatal care.

The previous assessment identified that staff did not always follow the sepsis six care pathway when women or birthing people showed signs of sepsis. During our review we saw the service used a Sepsis 6 Bundle and Sepsis trolley. The trust had introduced a sepsis tool and audit. There had been a rewrite of the Maternal Sepsis During and Following Pregnancy policy, this policy including a sepsis risk assessment.

Maternity and obstetric staff had met the training compliance of above 90% for Clinical Negligence Scheme for Trusts (CNST) for fetal monitoring. All staff had competency tests and had scored 85% or above.

Women and birthing people were supported to develop personalised care plans with their midwife or obstetrician which identified wider health needs and a plan of care. There was a focus on supporting complex case women and birthing people to have the birthing experience they wanted.

Frequent attenders to maternity triage were monitored via the daily auditing process and the service was 100% compliant with the care pathway set out within the frequent attender policy. Data showed that maternity triage had 13 frequent attenders attend over the last three months, with 6 attendees attending for planned visits and 2 women and birthing people admitted on their third attendance as per guideline. All frequent attendees admitted to the maternity unit went to the labour ward and were reviewed by the senior obstetric team.

Neonatal and maternal readmission rates for the service were low. An audit of postnatal readmissions between January to December 2024 was completed and it showed the number of babies readmitted for jaundice and weight loss. Areas of good practice included the improvements in feeding management post birth, improvements in feeding support and discharge management and an improvement in checking bilirubin (a yellowish pigment produced during the breakdown of red blood cells) levels post 24 hours of birth.

All high-risk women and birthing people booked in for induction of labour had a fetal medical plan in place which detailed the location of the induction of labour and the method, and the consultant midwife had oversight of the inductions of labour.

The service did not always detect and control potential risks in the care environment. Staff did not always make sure equipment, facilities and technology supported the delivery of safe care.

The environment within the labour ward continued to look tired, with cracks in the flooring and paint-chipped walls.

The Day Assessment Unit did not have a sluice room. This meant that women and birthing people’s urine needed to be tested in a small room and disposed of safely in the nearby Abbey Birth Centre sluice. There was no dirty laundry room, and we saw dirty laundry stored next to clean sheets.

We were unable to review whether safety checks were completed on emergency equipment in all maternity areas as we could not access this on the electronic system. Following the assessment, the service told us there were issues with reporting the data. Data reviewed showed quality spot checks were not being consistently undertaken on the labour ward. The service reported that this issue had been escalated following our assessment by the Director of Midwifery and the data analyst reported there was a solution for the data reporting issue.

Improvements had been made to the maternity triage area following our previous assessment, with significant improvement found within all areas of triage.

The triage department was well signposted and on arrival women and birthing people were met by staff and shown to a small waiting area. We did not see this area becoming overcrowded or too full. Since our previous assessment, the service had created an area with a separate room for women and birthing people to be assessed. The triage area had 2 beds with a curtain that went across each bed. The area was clean and uncluttered with plenty of space.

There were several previous concerns raised regarding elective caesarean sections taking place within main theatres in the main building during the last assessment. Concerns were raised about women and birthing people being looked after in a mixed sex recovery unit following their caesarean. Women and birthing people continued to follow the same process of having their elective caesarean sections within main theatres. However, they were not now in a mixed sex bay within recovery.

There had been a huge focus on improving the experience and safety of elective caesarean sections for women and birthing people. The service spent a large amount of money on refurbishing and improving the ventilation and infection, prevention and control within the second maternity theatre currently within the unit. We saw this work had been completed, and the plan was to repatriate all elective caesarean sections. There was a financial bid to make the high dependency room next to maternity theatres a recovery room for women and we were told by senior leaders this was likely to be agreed. The plan was to start elective caesarean sections in the maternity theatres from April 2025.

The maternity unit was fully secure with a monitored entry and exit system and the service had completed baby abduction drills. The service had suitable facilities to meet the needs of women and families.

Most equipment and store cupboards were visibly clean, tidy, and uncluttered. However, there was an excess of out-of-date equipment within the labour ward storerooms. This information was fed back to the senior maternity leads and the service removed the out-of-date equipment.

The milk fridges were checked daily to ensure they were maintained at the correct temperature for safe storage.

The service had a purpose designed bereavement area to help support women, birthing people and their families, called ‘the Daffodil Suite’. The bereavement area was situated on the labour ward, on a separate corridor.

There were birth pool evacuation nets and equipment in every room that had a birthing pool, and the service completed weekly safety compliance checks of equipment following the concerns about a lack of equipment during the last assessment.

The service made sure there was enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care that met people’s individual needs. However, mandatory training compliance for midwifery and medical teams did not meet the trust target of 90%. The midwifery team had 85% compliance and the medical team 85.7% compliance.

There had been an improvement in staffing over the last 12 months and the maternity service was near to establishment. The service had a vacancy rate of 25% in September 2023 and in October 2024 this had improved to 16%. Band 5 and band 6 vacancy rate was 32% in September 2023 and had improved to 13% in October 2024.

Staff we spoke had mixed views of current staffing levels, with not all staff feeling that staffing had improved. Staff told us that, although numbers in maternity areas had increased, shifts were not always filled due to sickness or leave which meant staff were often pulled from other areas.

Senior leaders told us the service was due to commission for a recognised national midwifery specific staffing tool to review staffing. The tool used reviews intelligence and insights within the unit to be able to ascertain the safe number of midwives and maternity support workers required within the unit

There had been an obstetric workforce review which had seen an investment and expansion in consultant and middle grade doctors. This meant the establishment was within national guidance.

The directorate had 16 consultants with 4 who specialised in obstetrics only. Consultants were physically present within the unit between 9am to 11pm and then completed on-call from home. Gynaecology and maternity day assessment and triage cover were now separated with protected cover from 9am to 9pm when the acuity was at its highest.

Maternity and medical teams met the trust compliance with 95.9% for obstetric emergency training including neonatal life support.

The service was proactive in training midwives in advanced neonatal life support. There were 29 midwives, and 1 registered nurse trained, with a further 25 midwives booked to attend between March and September 2025.

Fetal monitoring training compliance for both maternity and medical teams were 90.4%, with outstanding obstetric doctors due to complete the training in March 2025.

The service assessed and mostly managed the risk of infection. Staff mostly detected and controlled the risk of it spreading and shared concerns with appropriate agencies.

The previous assessment had identified gaps within the cleaning records and non-compliance with infection control standards. The service had a new compliance lead supporting audit submission. There was adherence to infection, prevention and control (IPC) standards and ward audits. Although, data showed that staff did not always meet IPC targets within hand hygiene.

There was a standard operating procedure in place for completion of all IPC audits so that non-submission or completion of audits were reviewed.

Since our last assessment, service level performance scorecards included IPC data and area leads were given protected management time to complete audits.

The service completed a ‘theme of the week’ on IPC and hand hygiene practices and there had been ‘a tea trolley event’ at the beginning of March on the education of ‘the 5 stages of hand hygiene.

Staff regularly checked birthing pool cleanliness, and the service had a contract for legionella testing of the water supply.

The service had set a target of 70% compliance for IPC training, with 80% compliance for maternity staff and 85.1% compliance for medical staff.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Staff were trained to administer medicines safely. Staff demonstrated good understanding of how to monitor for and manage medical emergencies that can occur in pregnancy, including post-partum haemorrhages and sepsis.

The trust used an electronic based system to prescribe and record administration of medicines in Maternity. There were policies and procedures to support the safe and effective use of medicines.

Women and birthing people were supported to manage and administer their own medicines where appropriate. There were processes to ensure people entering services received the medicines they needed.

The pharmacy team supported the service and reviewed medicines prescribed. These checks were recorded in the prescription charts we checked. Staff completed medicines records accurately and kept them up to date.

Midwives had access to the full list of midwives’ exemptions, so they were clear about administering within their remit.