Furness General 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

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 has changed to good.

We assessed 8 quality statements. The service had a positive learning safety culture where staff felt supported when dealing with incidents. The service had made significant progress to improve safe systems of care. Staff met the trust target for safeguarding training and followed safeguarding policies. The service worked well with women to understand and manage risks and detect and control potential risks in the care environment.

The service ensured all staff completed mandatory training and received effective support and supervision.

Staff knew how to recognise, report abuse and worked well with other agencies. There were improved numbers of midwives and specialist midwives in post. We saw improvements in cleanliness, infection control and hygiene. The service made sure that medicines and treatments were safe and met women’s needs.

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 proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had a positive learning safety culture. Staff we spoke with told us there was a lot of support when reporting and dealing with incidents. They told us that they had dedicated time to have debriefs and discuss feedback from incidents. They also shared among the service for wider learning.

The service held an incidents triage meeting every morning where they looked at all incidents that had been reported over the previous 24 hours and decided on next steps.

Staff understood what incidents were and knew how to report them on the electronic system and we saw consistent reporting. All staff we spoke with said they were confident in incident reporting and that they were encouraged to report. They also received feedback and learning was shared. For example, we were told by staff about an incident of shoulder dystocia which resulted in additional skills drills to be implemented on their upcoming Practical Obstetric Multi-Professional Training (PROMPT) day where they used real life examples for learning.

We reviewed Learning from Patient Safety Events (LFPSE) incidents for the previous 12 months. LFPSE is a national NHS system for the recording and analysis of patient safety events that occur in healthcare.

From 28 February 2024 to 28 February 2025, the trust reported two serious incidents in maternity and from 1 March 2025 to 20 June 2025, there were 2 further serious incidents reported, however there were no never events recorded during this period. From 15 January 2025 to 10 June 2025, there were 625 LFPSE notifications reported as incidents in specialties relating to maternity. The majority (472) were classed as causing no physical harm. Previous incident analysis was carried out for LFPSE notifications received from 14 January 2024 to 14 January 2025, where there were 1,350 events recorded on LFPSE relating to maternity services that were reported as incidents. This data was not split by site, therefore these are service wide totals.

We spoke with external partners and stakeholders about the learning culture and feedback was positive. There were positive examples of when the trust has responded effectively to concerns raised.

There was a triage process in place to review incidents daily for all incidents reported over the past 24 hours and the service had weekly divisional meetings to discuss incidents in more detail, including what incidents were outstanding. We saw levels of harm relating to post-partum haemorrhage (PPH) were consistent and the trust policy prompted staff to report PPH as an adverse incident on the trust's electronic incident reporting system. We were assured all incidents were reported correctly and that managers had clear oversight of clinical risk.

The unit had identified a higher number of women with post partem haemorrhage above 2 litres and were undertaking a thematic review of those losing above 2 litres of blood at the time of our inspection. 

Learning from incidents was shared with the board, through the maternity and neonatal report. The latest report showed leaders worked with the Local Maternity and Neonatal System (LMNS) to monitor and continually improve their performance.

The service took action to learn from incidents and to identify areas of improvement. We were told that the day assessment unit midwife now carried a cordless phone to enable them to make emergency calls in a more timely way as a result of learning from an incident.

The trust undertook PMRT reviews to scrutinise events leading up to deaths to identify whether anything different could have been done that may have changed the outcome for the mother or baby. We reviewed these as part of our inspection and found the notes to be comprehensive. Women and families were included in reviews and offered the chance to ask any questions and seek clarity about decisions made about the care and treatment they received. Lessons learned were identified and named individuals were given responsibility for making sure action plans were developed and progressed. We reviewed the action log which showed actions were regularly reviewed and progressing. The action log also identified actions from cases referred to Maternity and Newborn Safety Investigations (MNSI).

At the time of our inspection the service had been under the Maternity Safety Support Programme since 2021 and were working towards their exit. They entered the sustainability phase in 2023 and were awaiting an assurance visit with a view to being fully compliant.

The service had safety incident policies that were comprehensive, in date and had been reviewed to reflect the most up to date national guidance.

Senior leaders attended monthly safety meetings to discuss patient safety incidents in more detail. We observed minutes from meetings that identified areas of learning with associated actions.

We scored the service as 3. The evidence showed a good standard. 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 used newborn early warning trigger & track (NEWTT) and modified early obstetric warning score (MEOWS) tools to detect and escalate deterioration quickly. We reviewed 10 women's records and 10 babies records and saw that these were fully completed and scored appropriately. The trust also audited compliance of NEWTT and MEOWS. They were assured managers had sufficient oversight of compliance and escalation.

The data we received regarding MEOWS audits was across sites and not split, therefore we were unable to determine whether any issues were at one site or across the trust.

Following the national implementation of the Maternity Incentive Scheme, the service had improved the assessment and monitoring of venous thrombo-embolism (VTE) assessments. They maintained oversight at governance meetings since the focus of VTE assessments at the booking appointment, and reassessments on admission of 6 hour stays, admission of 14hr stays and 6hrs post birth. A weekly email (in place since 2023) was sent to all leads, matrons and managers, of admission and postnatal VTE assessment completion percentages in the previous week. This allowed local oversight and escalation if areas were decreasing in compliance.

It was identified in the last caesarean section audit there were women that were not getting the correct prescription for Low-Molecular-Weight-Heparin (LMWH). Therefore, the service carried out a combined audit for VTE assessments and prescription reviews.

A follow up audit in October 2024 showed that all women who required LMWH were prescribed it.

Documentation audits (including pain management and consent form audits) to include findings and associated action plans for the 6 month period prior to our assessment. We reviewed records audits provided by the service which showed 100% compliance including, recording of referral to the smoking cessation service, minimum set of antenatal results, offer of fetal anomaly screening, antenatal booking assessment and reviews, individualised management plan and referral to consultant where required. The only metric which fell short of the target was pregnant women who were cared for by a named midwife throughout their pregnancy, which was 79%.

We were assured that risk assessments were completed at every antenatal visit and reviewed throughout, and all documentation completed by maternity staff was in accordance with best practice guidance and trust policy.

Compliance with documentation of cardiotocography (CTG) was monitored though peer review and schedules audit. Data we reviewed from their previous audit showed 60% compliance for completing hourly ‘fresh eyes’ assessments.

Some intrapartum management plans were not completed and CTG monitoring documentation was not always on time. There were also times where the fresh eyes were late, or doctors had not used the correct proforma regarding a CTG review but if they had documented a clear review in the same entirety, it was included as compliant.

We reviewed 10 women's records and found no gaps in documentation being signed at the end of the CTG and no gaps in staff completing the ‘fresh eyes’ during our inspection. This showed an improvement since their last audit.

We saw that risk assessments were completed in women’s records that we looked at. These included assessments of venous thromboembolism (VTE), smoking during pregnancy, domestic abuse and mental health.

Women could access support from a perinatal mental health specialist team. The service had a specialist perinatal mental health midwife who offered mental health clinics including joint clinics with a consultant.

The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met women’s individual needs.

The trust provided comprehensive mandatory and specialist maternity training and ensured that all staff completed it.

We reviewed compliance against mandatory training targets and saw that all staff achieved over 90% with the exception of departmental Fire Training at 87%, Mental Capacity Act (MCA), Deprivation of Liberty Safeguards (DoLS) at 85% and Aseptic Non-Touch Technique (ANTT) at 73.3% 

The service followed the core competency framework which requires 4 mandatory study days per year and maternity support workers attend 3 of them. The community midwives completed 4 of them and an additional community Practical Obstetric Multi Professional Training (PROMPT) day.

Midwives and obstetricians all attended the multi disciplinary study days and anaesthetists attended 1 PROMPT day. Bank staff were included in the study days and could not book shifts if they were not fully compliant. The service was not using any agency staff. Staff completed study days for additional mandatory training relevant to their role including maternity update days, maternity obstetric drills and fetal well-being days.

As part of the maternity study days, an outside speaker attended to discuss mental health and learning disabilities.

The maternity obstetric drills study day covered a wide range of obstetric emergencies across the birth centre, such as postpartum haemorrhage, shoulder dystocia, resuscitation and pool evacuation.

Basic Newborn Life Support education, training and competency assessment was completed annually by all maternity staff. This training was delivered by qualified Newborn Life Support (NLS) instructors. Labour ward coordinators and community midwives attend the Resuscitation Council NLS training every 4 years. The Trust facilitated NLS training courses twice a year.

The service had 14 trained professional midwifery advocates (PMA’s) across the trust to support professional development and supervisions. They had increased their visibility as they had changed to a rota system and were implementing support for band 5 midwives through preceptorship study days. The PMAs had also implemented a ‘PMA of the day’ across all sites to attend safety huddles and to be a dedicated support available to midwives for the entire day.

The service also had a preceptorship and retention midwife, practice development midwives and a multi professional educational team. Comprehensive educational sessions were planned in a structured schedule and staff we spoke with confirmed training was never cancelled.

We observed that midwifery staff were recruited in accordance with trust policy and all personnel documents were stored electronically in individual files. Upon appointment, all midwifery staff received a formal trust and departmental induction.

We were told that band 5 staff attended an induction week. Others were planned by managers and mentors and tailored to the needs of the individual with the support of the education team.

The regional preceptorship survey identified the trust as having received consistent positive feedback from new midwives. Student midwives we spoke to during our inspection spoke very positively of the service and shared plans to remain there once qualified.

The service was aligned to the National Preceptorship Framework; band 5 staff had 4 weeks supernumerary and 2 weeks in any new area rotated. Others had 4 full weeks supernumerary as standard; however, service leads told us that they would remain supernumerary until they were confident. For example, some international midwives may require further time to become familiar with equipment and guidelines. Supernumerary status enabled newly registered midwives to ensure they had dedicated time for learning and practice in accordance with best practice guidance and trust policy.

Service leads 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 always aware of any emerging 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, fulfillment 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 7.17 whole time equivalent (WTE) against Birthrate+ recommendations. When we met with the senior leadership team, they told us the FGH maternity team had recruited to all vacancies at the time of inspection, but there were still gaps until the newly qualified staff joined the team in September. 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 at all times.

Managers regularly reviewed and adjusted staffing levels and skill mix and gave bank and agency staff (although no agency staff used in over 18 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.

The service reported maternity ‘red flag’ staffing incidents in line with National Institute for Health and Care Excellence (NICE) guideline 4 ‘Safe midwifery staffing for maternity settings. A midwifery ‘red flag’ event is a warning sign that something may be wrong with midwifery staffing. Between March 2024 and March 2025 there were 82 red flag incidents,

41 of these were due to the team leader not being supernumerary on the shift. The remainder were the delay between admission and induction of labour. These were reported through the Birthrate Plus acuity tool and escalated through the management team.

The service had designated midwives for triage who were trained in the use of BSOTS. BSOTS is the Birmingham Symptom-specific Obstetric Triage System (BSOTS) and is a standardised system used in maternity triage to assess and prioritise women with unexpected pregnancy-related concerns.

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 was not able to be supernumerary. We looked at the BSOTS triage information and saw the triage target was not always being met. In April 2025 at FGH, of 240 attendances, 89% of women were triaged within 15 minutes which showed fluctuations in numbers, however all were documented with reasons for delays and ongoing plans. At the time of our inspection we did not see any breaches of this standard in the records we reviewed on site. There had also been no incident reports of moderate or serious harm as a result of the delays.

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.  

We requested compliance rates against the trust target for performance appraisals for all maternity staff groups. Data provided stated the trust target to be 85%, however the overall compliance for maternity at Furness General Hospital was 67.7%. The least compliant staff groups were community midwives and community maternity support workers.

The service acknowledged that some areas were reporting below the trust target. The area leads were focusing on an improvement trajectory for all staff who were out of date, to ensure the trust target of 85% was met by 30 September 2025.

There were operational huddles twice a day to review capacity and staffing in addition to daily site management meetings that took place four times a day. Since our last inspection we saw improved numbers of midwives and there were now 15.7 whole time equivalent (WTE) specialist midwives in post. This included a perinatal mental health midwife, a team of enhanced support midwives and the safeguarding midwives.

During our inspection we spoke with medical staff of different grades. They told us they enjoyed working at FGH. 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 first and second 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 (77%), and infection prevention and control level 2 (75%).

The consultants working within the FGH maternity and gynaecology team told us their work plans 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 resident doctor. There was also anaesthetic cover available 24/7 for the two theatres, one of which was dedicated to elective caesarean sections and the other for unplanned or emergency maternity cases.

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. 

Consultant capacity and job plans were regularly reviewed and incorporated into the trust wide obstetrics and gynaecology workforce strategy.

There was a formalised induction process for locum doctors and the policy for managing locum medical staff induction was referenced, version controlled and ratified. This meant we were clear how the trust was assured locum medical staff received a formalised induction, were supported to practice in accordance with trust policy and fully trained regarding trust emergency procedures.

We reviewed the trust policy for staffing escalation and mitigation to include out of hours consultant and anaesthetic cover provision.

The evidence showed a good standard. 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.

We saw improvements in cleanliness, infection control and hygiene. The service had cleaning schedules in place and clinical areas we saw were visibly clean and had suitable furnishings which were clean and well-maintained. For example, upholstered couches and patient seating were impermeable and could be wiped clean.

Each area of the maternity unit had a dedicated cleaner. Cleaning staff used checklists in clinical areas to evidence that areas were cleaned, which we reviewed and saw no gaps. Each clinical area of the unit had a bespoke list of cleaning tasks, cleaning frequencies and responsibilities. Staff cleaned equipment after use. The service had implemented a system which entailed laminated, green tags being attached to items that were clean and ready for use. We saw these being used consistently across the unit.

The service disposed of clinical waste safely and sharps bins were used correctly.

Staff accessed hospital infection prevention and control policies on the intranet. Staff followed infection control principles including the use of personal protective equipment (PPE). We observed staff complied with ‘bare arms below the elbows’ policy, in accordance with NICE guidance. We observed staff washed their hands and used hand sanitising gel between interactions.

We reviewed hand hygiene audits between January and June 2025 and saw 100% compliance across the service at Furness General Hospital (FGH). This meant that we were assured staff hand hygiene practice was in accordance with policy and national best practice guidance.

The service had an effective system in place for curtain changes. We observed disposable curtains across the unit all had dates to be changed and these were monitored by the cleaning team and changed ahead of this date if required.

Regular environmental cleanliness audits were completed. We saw a marked improvement over the reporting period, from 65.9% to 80.5%, with most failures because of a poor estate. All estate jobs had been requested and remained outside of the division’s control. Audit actions continued to be monitored and updated by the ward manager, with oversight from the matron. Infection prevention and control teams were aware of the issues as well as senior leads.

There was a dedicated clinical pharmacist who supported the unit. Staff told us they had access to support and advice about medicines when needed including out of hours. Pharmacy staff told us there was a medicines safety “bus” that supports learning around medicines incidents.

Medicines were stored securely. The service used a remote temperature monitoring system for rooms storing medicines and medicines fridges that would alert staff if there was any deviation from recommended guidance.

We reviewed records where we saw a woman who was admitted with a potential sepsis diagnosis. They received antibiotics within 1 hour. The trust had specific policies for managing sepsis in maternity and labour. The trust had a deteriorating patient group that reviewed sepsis cases to check they were managed safely.

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 and there was a system in place to manage the storage and use of controlled stationery. There was access to pre-packed iron tablets to avoid delay in discharges if required however this was new and had not yet been fully embedded.

The service used an electronic prescribing system to prescribe and administer medicines (EPMA) 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. For medicines prescribed to prevent blood clots the trust policy stated that the weight should be recorded at booking in and 36 weeks, however for 4 records checked who were beyond 36 weeks we saw that an up-to-date weight was not always documented.

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

On the unit there was a dedicated, secure fridge where breast milk could be stored. We observed the expressed breast milk fridge was locked and bottles were clearly labelled with expressed dates and women’s names. Inside the fridge there were individual boxes with combination locks to prevent access to another woman’s milk. Bottles were checked and removed after expiry.