Royal Lancaster Infirmary

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

This means we looked for evidence that women were protected from abuse and avoidable harm.

At our last assessment we rated this key question Requires Improvement. At this assessment the rating remains as requires improvement. This meant women were mostly safe and protected from avoidable harm. However, medicines management needed to improve.

We assessed all quality statements for this key question.

The service had not always had a positive learning safety culture where staff felt supported when dealing with incidents. However, the service had made progress to improve safe systems of care and implemented changes to incident reporting processes to support this.

Staff training figures had improved since our last inspection and the 90% target had only been missed on 6 occasions out of 69 across the entire training suite including midwives and obstetricians. Staff met the trust target for safeguarding training and followed safeguarding policies. The service worked well with women to understand and manage risks or detect and control potential risks in the care environment. Staff knew how to recognise and report abuse and worked well with other agencies.

There were improved numbers of midwives and specialist midwives in post. There were sufficient midwives, doctors and support staff deployed to meet the needs of women using the service. The service had also made improvements to the triage process.

We saw improvements in cleanliness in most areas and there were also improvements in infection control and hygiene.

The service did not always make sure that medicines and treatments were safe or met women’s needs. We found a breach of Regulation 12, Safe Care and Treatment in respect of medicines.

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.

There was a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events were investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

The trust had a policy for reporting safety events including serious incidents that we reviewed, This was in date and accessible to staff. It contained a flow chart which showed staff how to report an incident and what happened to incidents of different severity after they had been reported. All incidents were triaged daily by a team of maternity leaders who further decided whether duty of candour was required and whether the incident should be classified as a serious incident for an in-depth investigation. The policy also clarified lines of staff responsibility.

We specifically asked the trust to send us information about the last 10 incidents relating to short staffing. 4 of these related to Royal Lancaster Infirmary. All were classified as low impact. 3 occasions led to the home birth service being suspended and one led to a patient being delayed in receiving important time specific medication. Incidents were discussed and where appropriate, lessons learned, or changes made.

Senior leaders met daily to look at recently reported incidents, discuss whether they were categorised correctly and what if any actions needed to be taken, such as investigations or further information gathering. This was done to make sure any early learning was identified and staff informed via safety huddles.

We spoke with staff about reporting incidents, and they all told us they knew what and how to report. We saw incidents were reported by all disciplines of staff at all grades. Some staff told us there were occasional delays in reporting incidents because of staffing challenges as they prioritised women’s needs, but all staff told us they made time to submit incident reports. We also asked staff about their understanding of Duty of Candour, and they were all able to give us a summary which was in line with Duty of Candour requirements. There was a Duty of Candour policy in place which staff could access easily if they needed to.

We reviewed LFPSE (learning from patient safety events) submitted by the trust between June 2023 to June 2025. There were 537 events recorded across the trust relating to midwifery, obstetrics and gynaecology. The information was not split by site. The data was broken into 3 categories, Risks (440), Incidents (81) and Outcomes (16). The levels of concern were; no concern at all (40), not very concerned (134), fairly concerned (254) and very concerned (109). We reviewed the ‘very concerned’ entries and found these to be mostly related to staffing.

We also reviewed PSIRF (patient safety incident response framework) incidents for the last 12 months. There were 1111 incidents reported for Royal Lancaster Infirmary maternity services. Each was graded by level of harm and 600 of these were graded as no injuries, 451 were graded as low harm, 33 as moderate harm, 1 long term or permanent harm, 8 deaths including maternal and still births and 10 as demonstrations of excellence by staff members.

We further looked at learning from events reported to MNSI (Maternity and Newborn Safety Investigations) and PMRT (Perinatal Mortality Review Tool) investigations. Action plans with specific responsibilities were developed to make sure learning was shared across multi-disciplinary teams and departments.

The trust used newsletters and flyers to inform staff of incidents and lessons learned. These were shared monthly and included both midwifery and medical staff. They also advised staff of any changes and updates to relevant policies. Lessons learned and incidents were also discussed at team meetings and safety huddles. Where a member of staff was involved in an incident or complaint, this was discussed with them at their monthly 1:1 meeting.

We work with women and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when women move between different services.

The evidence showed a good standard of systems, pathways and transitions for women. The service worked with women and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when women moved between different services.

We reviewed the latest CQC Maternity Survey results from 2024 and saw the trust performed ‘About the same’ as other organisations in relation to involvements in decisions, opportunity to ask questions, and ‘Much better than expected’ in relation to information and explanations after birth.

The care, treatment and support women received was planned in collaboration with women, their families, health care partners and care providers. It was done in a way that maximised continuity of care throughout the person’s pregnancy pathway as much as possible. The referral and admission processes of the service ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. Board rounds took place throughout the day to ensure teams were fully aware of the presence and status of all women.

Safety huddles and handovers took place in the different units of the maternity service at shift changes to make sure all staff including the labour ward coordinator, and ward manager were up to date with the status of the department and patients within it. All staff attended these meetings or were provided with feedback if they were attending to patients.

Vulnerable and high-risk women were supported by community midwives who built relationships with women over time, building trusted links within communities. Women were also able to access the day assessment unit if they were concerned about their pregnancy at any point. The trust worked to make sure women received continuity of care throughout their labour journey.

Staff told that an increasing number of women had higher risk pregnancies due to health conditions and lifestyle choices. Women who were identified as having an elevated risk pregnancy had risk assessments and personalised care plans put in place. These were completed with women and were in place to ensure women received treatment and care in line with national guidelines throughout their pathway.

Staff placed women in the most appropriate setting whenever possible to make sure they received the most appropriate care to meet their needs. Staff told us there were very few times when women were at risk of not receiving the most appropriate care and support to meet their individual needs.

The trust worked with women to understand what being safe meant to them as well as with partners on the best way to achieve this. The trust concentrated on improving women’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and the trust made sure to share concerns quickly and appropriately. Trust staff were aware of the risks to young people relating to sexual exploitation and acted appropriately when necessary.

The evidence showed a good standard of safeguarding training and understanding. The service worked with women and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving women’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. Trust staff were aware of the risks to young people relating to sexual exploitation and acted appropriately when necessary.

Staff were trained in safeguarding, were able to easily access the trust’s safeguarding policy, knew how to make safeguarding alerts, and did so when appropriate. We saw examples of safeguarding referrals and spoke with staff who explained the process including who to involve and where they could access support from.

Safeguarding training figures varied across staff groups. Obstetricians achieved 100% compliance for level 3 Adults and Children safeguarding, 98.1% for midwives at level 3 and 94.4% for midwifery support workers at level 3. This met the trust standard of 90%. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act (2010). They explained how they made sure women had opportunities to disclose any safety concerns they had to staff in discreet ways.

Staff knew how to identify adults and children at risk of harm. This included working in partnership with other agencies. We observed discussions about vulnerable women and what measures were put into place to support any additional needs they had. This included but was not limited to, domestic violence and mental health support.

Staff followed safe procedures for children visiting the service. They told us they understood their responsibility in relation not only to women but also visitors.

We saw evidence that the service had instigated a number of baby abduction drills in the last 12 months to make sure staff knew what to do in the case of a real abduction attempt. The service told us they planned regular abduction drills throughout the year in different departments of the service, and we saw drills had been carried out in the labour ward and the ante/post-natal ward.

The trust had a procedure for reporting female genital mutilation (FGM) and clarified FGM was part of routine enquiry at antenatal booking appointments. If any type of FGM was disclosed, a referral was made to the safeguarding team. This ensured the service had full oversight of safeguarding and FGM concerns. Staff told us FGM was uncommon but that they would report occurrences in line with national guidance and would offer specialist support to women who presented with FGM.

We work with women to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

The evidence showed a good standard of involving people to manage risk. The service worked with women to understand and manage risks by thinking holistically. Staff provided care to meet women’s needs that was safe, supportive and enabled women to do the things that mattered to them.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients who needed extra support to communicate. This included using interpreters or communications aids where appropriate. Staff ensured that women could access advocacy services if they wanted to. Women were given the time to ask questions and have meaningful input into decisions about their care.

Women were supported to manage the risks within their pregnancy and make decisions about antenatal, delivery and postnatal care and treatment. This included decisions about where to give birth and the type of birth they wanted. Birth plans were a collaboration between women, their families and health professionals.

We observed daily safety huddles that incorporated discussions about the potential risks of birthing women. Twice daily bed management and flow meetings were also carried out to address any potential service pressures.

Women could call the delivery suite and talk to an experienced midwife if they had any concerns. They could also attend the department and be assessed by a midwife who could escalate any concerns identified or reassure women. Staff told us the telephone service could be busy with calls sometimes diverted to other sites but that women still received the advice they needed.

Staff carried out fetal wellbeing monitoring using a process called cardiotocography (CTG) The trust did not have a central monitoring process which enabled senior and more experienced midwives and obstetricians to continually monitor the condition of women and identify and escalate any signs of deterioration or difficulty in a timely way. However, individual staff and coordinators were able to access the multi view CTGs from any computer. The trust was awaiting implementation of a centralised monitoring system. CTGs were recorded on an IT system that all staff could access and were signed off by two qualified staff one of whom was usually the coordinator. As part of their role, the coordinator reviewed CTGs and was a fresh pair of eyes on CTGs. Centralised CTG monitoring is a recommendation from Dame Donna Ockendon’s maternity review which the trust was not meeting.

Staff enabled patients to give feedback on the service they received, and we saw patients could book a meeting with the midwifery team to talk about what went well and not so well about their birthing experience. These meetings were also a chance for women to ask questions. Themes and trends from these meetings were also fed back to teams to help improve women’s experiences. Women were encouraged to feed back to the hospital about their pregnancy experience, including community midwives.

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

At the time of the inspection, the delivery suite and surrounding area was undergoing redevelopment and building work to improve the overall footprint and facilities available to women using the service. This meant that access to the department had changed and there was a smaller footprint in the interim. The result was that the surrounding corridors were being used to store equipment and the rooms within the delivery suite had been reconfigured leading to the area feeling overfull and cluttered. Risk assessments of the area had been undertaken to make sure women and their families were not put at risk due to the changes.

We carried out checks on the environment and equipment such as resuscitation trolleys across the department. These were regularly checked to make sure all equipment was present and in date, including ligature cutters. The two pieces of equipment we found out of date were replaced immediately by staff. Other equipment we reviewed had been safety tested and serviced in line with their maintenance guidance. However, as we inspected the environment, we did observe oxygen bottles not properly secured and boxes being stored directly on floors as well as Entonox and oxygen cylinder access being blocked by chairs.

We reviewed delivery rooms and found that with the exception of one room, equipment was safe for use. Staff told us that the resuscitaire in one room was not to be used however there was no signage to indicate this on the piece. There was therefore the risk that the equipment could be used inappropriately. We brought this to the attention of the nurse in charge who made sure a clear sign was added.

Staff and patients told us that during the summer months and through recent heatwaves, the temperature on Ward 17 was excessive. The trust was aware of the problem and had provided fans and covered windows with heat reflective film in mitigation. The trust acknowledged this had limited effectiveness but due to the fabric of the building the installation of air conditioning wasn’t possible.

During the inspection we saw women could reach call bells in ward areas and feedback from women and their families at the time was that staff were responsive to requests for help and support in a timely manner.

The service did not always have enough suitable equipment to help them to safely care for women and their babies. For example, during inspection, a number of staff told us there was a shortage of tablets used for completing recording of observations onto the electronic records system. This was because the tablets kept freezing, had poor battery life and did not always have protective cases to stop them being damaged. The management team were aware of the issues and working on solutions. Staff also told us it was sometimes difficult to access pulse oximeters and cardiotocography (CTG) machines equipped with Dawes Redman analysis. CTG is widely used in pregnancy as a method of assessing fetal well‐being. CTG monitors equipped with Dawes Redman analysis are used before birth (antenatally) to monitor the baby’s well-being.

Staff carried out daily safety checks of specialist equipment such as emergency equipment. This system showed checks were carried out daily with no exceptions.

Clinical waste was stored correctly and securely. Sluice rooms were locked and only accessible to staff.

We looked at fridges storing breast milk and found these to very well organised with lockable compartments for each woman to store her own breast milk. Temperature checks were carried out to make sure milk was stored at its optimum temperature keeping it safe for use.

The maternity unit’s access was fully secure. There was a monitored buzzer entry system to the delivery suite, antenatal ward, and the post-natal ward.

We make sure there are enough qualified, skilled and experienced women, who receive effective support, supervision and development and work together effectively to provide safe care that meets women’s individual needs.

The evidence showed some shortfalls. 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 together well to provide safe care that met people’s individual needs.

Heads of midwifery and matrons met monthly to look at staffing in each of the maternity departments across the bay. We reviewed minutes of the Maternity and Neonatal Quality and Safety Group and monthly Safe Staffing reports. These demonstrated senior leaders were aware of the staffing challenges faced in maternity services and actions, initiatives and mitigation were being put in place.

We reviewed the midwifery workforce review produced in April 2025. Its purpose was to provide assurance of effective midwifery workforce planning and provided in part, fulfilment of requirements of the Maternity Incentive Scheme (MIS) Year 7 Safety Action 5. It detailed the increase in acuity of patients year on year, leading to changes in staffing requirements.

Managers used the Birthrate+ tool plus professional judgement to calculate the number of staff needed. In April 2025, maternity services had a surplus of 2.68 WTE (whole time equivalent) against Birthrate+ recommendations. When we met with the senior leadership team, they told us the RLI maternity team had some vacancies at the time of inspection but these had been recruited to with newly qualified staff joining the team in September after graduation. The trust had implemented a 3-year recruitment and retention strategy, supporting staff with targeted interventions to improve retention and reduce turnover.

The service had employed enough maternity staff with the right qualifications, skills, training and experience to keep women safe from avoidable harm and to provide the right care and treatment. The service was able to provide 1:1 care in labour. Staff training figures had improved since our last inspection and the 90% target had only been missed on 6 occasions out of 69 across the year and the entire training suite including midwives and obstetricians. Managers regularly reviewed and adjusted staffing levels and skill mix and gave bank and agency staff (although no agency staff had been used in over 6 months) a full induction. Managers limited their use of bank and agency staff and requested staff familiar with the service whenever this was needed and possible. Managers accurately calculated and reviewed the number and grade of midwives and midwifery support workers needed for each shift in accordance with national guidance. Staff from the maternity ward and delivery suite were on the same roster and could be moved from the ward to delivery suite when needed.

When we spoke with staff, they told us there were times when departments felt short staffed. They told us this was sometimes due to short term sickness and other times, due to acuity of women and skill mix. We looked at sickness levels in the department and saw absence in the delivery suite in June 2025 was 3.08% on ward 17 it was 1.08% and Ante Natal Care (ANC) 18.31%. Maternity leave was 4.17% whole time equivalent across the department. Sickness and absence were worse than the trust target and were subject to regular review and management to support staff. The sickness rate for all staff groups in the maternity core service trust wide, saw a decrease from 6.3% in March 2024 to 4.4% in March 2025. This decrease was largely driven by Midwifery staff, where sickness rates fell from 8.8% in April 2024 to 3.5% in March 2025. The department was working with midwifery staff to provide support to reduce sickness absences.

We reviewed maternity red flags submitted across maternity services at RLI. A midwifery red flag event is a warning sign that something may be wrong with midwifery staffing. We found RLI submitted 64 red flags between March 2024 and March 2025. For May 2024, there were 10 red flag delays, 8 were delays in induction and 2 were delayed caesarean sections and in June 2025 the delivery suite submitted 12 delayed or time critical activity red flags. This was reported on BirthRate+ however there were concerns highlighted by the trust, that the data for June may be inaccurate and single instances may have been reported multiple times. For Ward 17 there were 2 instances of delay in giving pain relief, 2 delays between admission and start of induction of labour and 1 missed or delayed care.

The service had designated midwives for in person and telephone triage who were trained in the use of the Birmingham obstetric symptom triage system (BSOTS). Midwives and Midwifery Support Workers (MSW) on maternity triage did not always feel that they had the appropriate number of staff when the service was busy. However, there was a clinical escalation process in place in the event that the co-ordinator could not be supernumerary. We looked at the BSOTS triage information and saw the triage target was not always being met. In June 2025 at RLI, of 361 attendances, 93% of women were triaged within 15 minutes and 97.5% were triaged in line with NICE guidance of 30 minutes. In May, 83% were seen within 15 minutes.

Managers worked with staff to make sure they had a robust induction, regular one to one meetings and that they had the skills and experience to carry out their role safely and effectively.

During our inspection we spoke with medical staff of different grades. They told us they enjoyed working at RLI. We asked about the culture within the department. Newer staff told us they had no concerns about the culture and those who had worked in the department longer told us the culture had improved and was continuing to do so. They told us lessons learned were shared and staff were more open when things didn’t go well, to facilitate learning and improvements in patient care.

Junior medical staff told us they felt well supported by their colleagues and were able to escalate any concerns confident they would receive the support they needed from more senior and experienced colleagues including consultants coming into the service if this was required. They also told us there was a good working relationship with midwives and a positive culture. We asked about workload and they told us it was sometimes busy, especially on call but was manageable. The 1st on call resident doctors have an on call rota of 1:9. The 2nd on call resident doctors, have an on call rota of 1:6.

They further told us they were given protected time to undergo mandatory training and teaching from the medical deanery and felt supported to attend other training when the service needs allowed. All resident doctors had to undergo PROMPT (Practical Obstetric Multi Professional Training) training and we saw the completion of this was 100% for medical staff. We also looked at training compliance for other topics and found medical staff were compliant for all mandatory training apart from Prevent (70%), and safeguarding adults and children level 2 (82.6), although 100% for level 3 safeguarding adults and children. We were concerned that not all medical staff had completed Prevent training. There was a risk because of this that people vulnerable to radicalisation may not be identified.

There were 12 consultants working within the RLI maternity and gynaecology team. They told us their workplans allowed them a good mix of clinical work and education and that on call was 1:6. They told us they sometimes provided 24 hour cover which meant attending the service overnight if their skills and experience were needed. Routinely, medical cover Monday to Thursday was from a consultant and resident doctor and Friday to Sunday from a registrar and resident doctor. There was also anaesthetic cover available 24/7 for the two theatres, one of which was dedicated to elective caesarean sections and gynaecology and the other for unplanned or emergency maternity cases.

Staff told us the biggest risks and concerns they had were around the fabric of the building, delays to induction of labour, 3rd and 4th degree tears and admission of full term neonates. These were all on the risk register and each was being closely monitored to look for themes and trends, with work ongoing to improve patient care.

We discussed incidents with medical staff. They told us incidents were reviewed and discussed regularly with peer review undertaken and personal feedback given as well as lessons learned shared with all colleagues.

For medical staff within the maternity core service, monthly sickness rate data was not always available for this period. In March 2025, the rate was 2.8%, similar to the 2.4% seen for medical staff across the trust.

We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

The evidence showed a good standard of infection prevention and control. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff maintained equipment and kept it clean. We saw staff cleaning equipment including bed frames, mattresses, blood pressure machines and CTG machines. However, there was no way for staff to identify if equipment was clean and ready to use.

All ward areas were clean, had IPC (infection prevention and control) furnishings and were well-maintained. Cleaning records were up to date and demonstrated all areas were cleaned thoroughly and regularly. We looked at cleanliness audit reports and found that all departments within maternity services at Royal Lancaster Infirmary were meeting the 98% cleanliness standard consistently across the year. When we reviewed PLACE (Patient Led Assessment of the Care Environment) audit results for RLI 2024 the site scored the same or similar as comparable organisations. Results were site wide and could not be broken down specifically to maternity services.

Staff adhered to infection control principles, including handwashing, wearing gloves and other personal protective equipment (PPE). We observed staff followed hand washing techniques in theatres, delivery suite and maternity wards.

Infection prevention and control training was mandatory for clinical staff at RLI and was set at 2 levels. Compliance for level 1 ranged from 97.1% to 100 and for level 2 ranged from 84.5% for midwifery staff to 100% for medical staff. Therefore, midwifery staff were not meeting the trust standard of 90%.

Leaders told us infection control was a consistent and important focus at each daily huddle discussion. Leaders told us about a rolling programme of audit that was carried out and supported constant improvement or change to practices where needed. All ward/unit areas displayed a clean star rating showing monthly compliance scores.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning

The concerns demonstrate a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We looked at medicine storage and records in the day assessment unit, delivery suite and ward 17. We reviewed medicines records for 6 women, spoke with 9 staff (4 midwives, 2 coordinators, 1 consultant 1 nonclinical support worker and 1 ward manager).

The maternity unit did not have a face-to-face clinical pharmacy service. However, staff told us they had access to support and advice about medicines when needed including out of hours. There was a lead pharmacist who had oversight of the service and supported with policies.

During our inspection there was a medicines error due to changes in the size of a vial of medication which remained at the same strength. Not all staff were aware of the change, and we found that there was no formal process for pharmacy informing staff of such changes to medications. This was a risk to patient safety because patients could be given an over or underdose of critical medicines leading them to come to harm.

Medicines were stored securely. The service used a remote temperature monitoring technology that would alert staff if there was any deviation from recommended guidance.

The service had a process for the supply of medicines on discharge. Staff had access to prescription pads to support women to receive their medicines in a timely way on discharge. Although there was a system in place to manage the storage and track the use of controlled stationary, staff did not always document when they had used forms and there was no policy to support this process. This increased the risk of prescriptions being lost or misused which in turn had the potential to put patients at risk.

The service used an electronic prescribing system (EPMA) to prescribe and administer medicines and a separate electronic system for recording of patients’ notes. Women’s weights were not always documented on the prescribing system meaning that staff would need to check both systems prior to prescribing. Due to the handheld devices not being able to access the EPMA system staff did not always have access to the patient’s record at the point of obtaining and administering a medicine to a patient. There was not always a contemporaneous record of the administration of medicine on the EPMA system. For one person we saw the midwife had not documented the administration of a medicine as they could not access the EPMA system. We saw for two women that prescribed infusions had not been stopped on the EPMA system. Records did not always demonstrate medicines were being administered as prescribed.

There was a process for medicines to be administered by midwives under the midwife exemption which supports women getting the medicines they need promptly. For one medicine that was supplied using a PGD (patient group directive) there was no record of which staff were authorised to use this directive. This could lead to women receiving this medicine in an unsafe way.

Staff completed audits related to medicines management and there was evidence of actions generated from audits.

There had been 21 Learning from patient safety events (LFPSE) recorded relating to medicine in the previous 12 months at RLI. These included documentation errors, wrong doses administered, stock discrepancies and missed known allergies. Maternity services had recorded these errors and worked with all staff to ensure lessons were learned.