St Helier Hospital and Queen Mary's Hospital for Children

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

We looked for evidence that safety was a priority for everyone and that leaders embedded a culture of openness and collaboration. We checked that women, birthing people, and babies were safe and protected from avoidable harm, neglect, abuse, and discrimination. We also checked that risk assessments, safeguarding, medicines management, and infection prevention and control were delivered in line with national standards.

At our last inspection, we rated this key question as Inadequate. The service was in breach of safe care and treatment, in relation to triage processes, management of medicines, privacy, dignity and respect, accurate completion of care records and the operation of effective systems and processes of maternity services. Since then, the service has made improvements in the management of incidents, appraisal, triage line, equipment, maternity assessment unit process, medicines, transitional care and recovery. However, there were still areas of concern relating to estate, staffing, triage process, training, patient record and risk assessment that had not been resolved from the previous inspection. As a result, the rating for safe has improved to good. This meant people were safe and protected from avoidable harm.

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. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There was clear evidence of a positive safety culture within maternity services at St Helier Hospital. Robust investigation processes were in place to ensure learning from incidents. The incident reporting system provided evidence of feedback to staff. Between April 2024 and March 2025, the trust reported 1,085 incidents across both maternity sites, all reviewed through daily maternity safety huddles. These huddles determined the harm level and the required investigation pathway, which may include after-action reviews (AAR), Patient Safety

Incident Investigations (PSII), or referral to the Maternity and Newborn Safety Investigations (MNSI) programme.

Staff we spoke with knew what incidents to report, how to report them and felt encouraged to do so. The service did not have set targets for incident closures; however, they aimed to complete all PSII’s within 6 months and monitored all incidents that were over 30 days old. At the time of assessment, the service had 1 AAR in progress that was over 30 days old and 1 PSII open over 6 months. However, both the AAR and PSII incidents were at draft stage and were awaiting final approval. An escalation system was in place to flag cases approaching their deadlines, and immediate learning was shared through safety huddles and governance meetings even while investigations were ongoing, to avoid delays in safety improvements.

We observed posters of incident trigger list and red flag events in the maternity unit which guided staff on what types of clinical and non-clinical incidents should be reported. Student midwives and preceptor midwives told us they found these posters useful. Duty of Candour was consistently applied in the incident reports and duty of candour letters reviewed, with documented evidence in maternity incident reviews and correspondence sent to families following care incidents and baby deaths.

Managers reviewed incidents regularly and involved women and their families in these investigations. They used an incident tracker to identify and monitor potential immediate actions and progress. Staff confirmed that they received individual feedback following incidents and that learning was shared widely through governance meetings, newsletters, and safety huddles. Debriefs were routinely offered after serious adverse events, and staff described these as supportive and constructive. Lessons learned from complaints were also disseminated through monthly governance meetings and maternity safety newsletters. For example, feedback about communication during induction of labour led to a review of the guideline, improved patient information and the introduction of QR-coded resources. Similarly, complaints regarding breastfeeding support prompted the introduction of dedicated infant feeding sessions and enhanced staff training.

The Southwest London maternity dashboard monitored neonatal deaths and stillbirths, and any spikes were investigated. The service neonatal death rates were better than expected. Perinatal mortality review tools and monthly meetings were in place to review care and deaths that occurred within the service, supported by Maternity Safety Support Programme (MSSP) updates and PSII learning themes.

Risk monitoring systems were comprehensive, including monthly audits of early observation warning signs and documentation audits that identified antenatal feeding improvements. Clinical strategy and standards group meetings were held regularly, and serious incident reviews were conducted through the Maternity Incident Review Panel which had met monthly, providing regular oversight of high‑risk cases, themes, and investigation quality. This process ensured that senior leaders-maintained visibility of safety concerns and learning, even when incident closures were delayed.

There were still improvements required to ensure women had timely access to an initial booking to the service and documentation of in-person triage sheets. However, the service worked to establish and maintain safe and continuous systems of care.

Women were generally able to access the unit as needed. The maternity unit had been closed 0 times in the last 12 months. Women could self‑refer online or by telephone, and referrals from General Practitioners (GPs) and community midwives were accepted, supporting multiple access points. Referrals were reviewed by the antenatal screening team and booked women to the service, enabling early identification of risk factors, safeguarding concerns and communication needs.

The service aimed to book pregnant women in by 9 weeks and 6 days gestation, in line with the national institute for health and care excellence (NICE) guidelines, which was monitored by the service. Women did not always receive their first midwife appointment within recommended timescales, limiting early identification of clinical and social risks. Although a referral process was in place, late referrals and increased demand led to delays in processing referrals and booking initial appointments. This could increase the risk of harm for women with complex needs or those less able to navigate the referral system. From June to November 2025, 71% of women were booked by 9 weeks and 6 days. However, the service achieved 90% compliance for bookings by 12 weeks and 6 days. The service did not identify a target for compliance.

All referrals were entered onto the Electronic Patient Record (EPR) system, ensuring information was immediately accessible to the multidisciplinary team. The booking pathway aligned with national guidance and included early screening and ultrasound scheduling.

Clear transfer processes were in place between clinical areas, supported by flow coordinators, a maternity bed manager, twice‑daily safety huddles, and use of the Operational Pressures Escalation Level (OPEL) framework to guide decision‑making. Where capacity was required, transfers to neighbouring trusts were facilitated via established Local Maternity and Neonatal System (LMNS) mutual aid arrangements.

The service had an in person and telephone triage line, which most women were initially assessed through before admission. The telephone line was effective at managing incoming calls, providing advice and liaising with the service to ensure appropriate information was available. The service included a dedicated telephone line outside of the trust, so women could have access to a midwife 24 hours a day, for help, advice and referral to the appropriate maternity service. The trust maternity services were part of the LMNS for the design and delivery of the maternity telephone referral and triage line, providing a single point of access for all maternity referrals in the areas. This was to ensure women had access to the right care as soon as they contacted the service. The purpose of the telephone triage line was to reduce the number of unnecessary attendances to the unit and provide immediate advice to women. Calls were triaged by dedicated midwives, in a private area away from the clinical area in line with the Royal College of Obstetricians and Gynaecologists (RCOG): Maternity Triage, Good Practice Paper.

At the last inspection, there were concerns that the triage telephone line was often closed due to sickness and absence, resulting in the triage line being diverted locally and abandoned calls. Data showed that between August and October 2025, the telephone line was open on average 90% of the time, reduced staffing was 2.7% and the sickness rate was 1.6%. This was an improvement from the previous assessment. The abandonment rate was related to mostly women that abandoned the calls after 3 to 4 minutes of waiting to speak to a midwife. In the event that the telephone line was not operating due to staffing, calls relating to the service were directed to a dedicated telephone line at the staff office on the labour ward, which was next to triage. The calls would be answered by any midwife, maternity support worker or doctor in the office if the triage midwives were busy. Staff told us that the telephone line was always answered in a timely manner, and there was always someone in the office to answer the triage calls. Staff told us and trust data confirmed that all midwives and maternity assistants working in triage and labour ward had received training and competency assessments on managing the triage telephone line. Staff were required to complete a structured triage telephone proforma on the electronic record system to support consistent questioning and escalation when they received a triage telephone call in the unit. We observed that staff completed the proforma appropriately during the assessment. This was an improvement from the last assessment. During the assessment the in-person triage was located in the labour ward area, triage now had a lead midwife who oversees the unit and was fully staffed. Triage also had 24/7 access to the obstetric doctors and consultant on the labour ward for reviews. This was an improvement from the last assessment.

In line with the triage local policy, women should be seen by a midwife within 15 minutes of arrival, and a RAG (red, amber and yellow) rating should be allocated based on their presentation. Each colour identified how soon women should be reviewed by a doctor or midwife as required. The September to October 2025 triage audit showed 100% compliance in the 15-minute initial review of women by the midwives. The service did not monitor the overall doctor waiting times for women reviewed within the allocated RAG rating, which meant we were unable to identify individual compliance of each rating. However, the audit data showed that 77% of women were reviewed by doctors within an hour. This was an improvement from the last assessment.

During our assessment, we observed staff did not always complete all entries on the time doctors were informed and time seen by doctors in the triage sheet. The November 2025 triage sheet showed 19.5% gaps in these entries, which raised concerns around contemporaneous record keeping and accuracy of audit data. However, staff we spoke to during the assessment told us that there were no delays in the review of women by doctors.

Handovers and safety huddles across the unit involved all relevant members of the multidisciplinary team. Shift changes and handovers included all necessary key information to keep women and babies safe. Handovers between teams followed the Situation, Background, Assessment, Recommendation (SBAR) model, ensuring that key clinical information, safeguarding concerns and outstanding actions were communicated consistently across areas and shifts. From May to October 2025, staff achieved 97% compliance against the 90% trust target.

Staff did not always complete safeguarding training; however, the service worked well with women and healthcare partners to ensure women and babies were safe.

The service provided adult and children safeguarding training that was comprehensive and included topics such as female genital mutilation (FGM), perinatal mental health, substance abuse and domestic violence. The training was delivered face‑to‑face by the children’s safeguarding team to a multidisciplinary audience. However, not all staff had completed it. The overall compliance rate for trust wide midwifery and medical staff was 82% which was an improvement from the last inspection but did not meet the trust target of 90%. We discussed this with the lead safeguarding midwife who reported that an action plan was being developed to improve compliance but that had not been completed at the time of our assessment.

The service had a maternity safeguarding and child protection guideline that was comprehensive, in date and in line with national guidance. Safeguarding processes were established and embedded, and staff demonstrated an awareness of safeguarding responsibilities, including recognition of abuse, neglect and discriminatory risks consistent with the Equality Act 2010. Safeguarding was routinely discussed at handovers, supporting continuity of information across teams and shifts.

The trust had a named safeguarding midwife supported by 5 specialist safeguarding midwives cross site, covering perinatal mental health, substance misuse and teenage pregnancy. These specialist roles contributed to effective case coordination and ensured safeguarding expertise were accessible to frontline staff. The safeguarding team identified domestic violence, substance misuse and perinatal mental health as the top safeguarding themes and risks, and had action plan in place to mitigate the risks. The service worked in collaboration with partners such as independent domestic violence advisors (IDVA), drug and alcohol nurses in the emergency department and a nearby NHS mental health trust to protect women and babies.

The service had an infant and child abduction policy and a guideline for newborn security. The baby abduction drill undertaken on 19 November 2025 highlighted several positive elements of practice. Staff challenged unauthorised individuals promptly, contacted emergency numbers without delay, and security teams responded quickly and completed identity checks. We observed managers reminding staff to observe and challenge any tailgating into the unit during handovers. One‑to‑one care and individual risk assessments were appropriately implemented for high‑risk women and babies.

Regular multidisciplinary meetings ensured safeguarding information was shared effectively, and actions were coordinated across professional groups. Staff were able to provide practical examples of how safeguarding policies were applied in day‑to‑day practice, including supporting individuals with protected characteristics under the Equality Act 2010. Staff also attended regular safeguarding meetings including case conferences, discharge planning meetings, child in need meetings and Multi-Agency Risk Assessment Conference (MARAC).

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service used nationally recognised tools to identify deterioration, including the Maternity Early Obstetric Warning Score (MEOWS) for mothers and the Newborn Early Warning Trigger and Track (NEWTT2) chart for babies. Audit data showed an overall 98% compliance with MEOWS completion and escalation between May and October 2025. Newborn risk assessments were consistently documented and reviewed, supporting early identification of deterioration and compliance with maternity guidelines. Staff reported good newborn and infant physical examination (NIPE) staff cover which was available 7 days a week and helped reduce any delay in discharge of women and babies.

Specific risk issues were managed well. Sepsis care followed the Sepsis 6 bundle, with prompt administration of antibiotics and fluids, although occasional sequencing errors were noted where antibiotics were given before blood cultures. Venous Thromboembolism (VTE) risk assessments were completed for all women reviewed, with audit data showing 100% compliance. Staff also monitored for falls and pressure ulcers, and psychosocial assessments were completed for women at risk of self-harm or suicide, supported by 24-hour access to mental health liaison and specialist perinatal mental health teams. The service held regular psychological and psychiatrist consultant led clinics for women with perinatal mental health and mental health conditions.

During surgical procedures, staff consistently completed the World Health Organisation (WHO) 5 Steps to Safer Surgery checklist, with audit data confirming 100% compliance between January and March 2025. Recent audit data from September to November 2025 showed 99% compliance with the WHO checklist.

During labour, high-risk women were monitored using a cardiotocograph (CTG), a device used to monitor fetal heart rate and uterine contractions. In line with NICE guidelines, CTG traces during woman’s labour, should be reviewed hourly by two clinicians (a process known as a ‘fresh eyes’ review). This is to ensure the baby is safe to continue with labour. Staff completed hourly fresh eyes in the notes we reviewed onsite. The service carried out 6 monthly audits of fetal monitoring and data showed an average of 83.3% compliance with fresh eye reviews between January and March 2025. This exceeded the local maternity and neonatal system (LMNS) target of 80%. This was an improvement from the last inspection.

We reviewed 10 sets of care records, which were completed correctly. These records demonstrated that appropriate action was taken on scores, staff assessed each woman’s health at admission, informed them of risks, and explained how to keep themselves safe. The management plan was also updated at each appointment in the notes we reviewed onsite. The management plan audit showed 83% compliance between the months of July and September 2025. A target was not identified for these assessments. However, staff achieved 100% compliance on completion of risk assessments in the same period.

Women also reported feeling involved in decisions about their care and supported to make informed choices. They reported that staff provided emotional support and advice when needed and ensured reasonable adjustments. Information promoting healthy lifestyles, such as smoking cessation and nutrition, were available on wards and discussed during antenatal and postnatal care. We also observed staff views being listened to at safety huddles and governance meetings and learning from incidents and complaints was shared widely.

Staff communicated effectively with women, so they understood their care and treatment. During the assessment, we observed staff using clear language and data showed there were visual aids available to provide alternative ways to communicate with those who had communication barriers, including translation services and British Sign Language (BSL) interpreters. Posters and QR codes linked to translated maternity information were displayed across clinical areas. However, during the assessment, we observed that birth plans were printed exclusively in English, which may pose challenges for women whose first language was not English, as their birth plans could not be printed in their preferred language. However, staff told us they would use interpreters and translators to discuss the information when indicated.

Although there had been an improvement in the estate since the last assessment, there were still ongoing and planned refurbishment and improvement plans for the estate. However, staff worked hard to make sure equipment, facilities and technology supported the delivery of safe care.

The maternity unit operated 24 hours a day, seven days a week, and had secure entry and exit systems monitored by ward clerks and maternity staff. The design of the maternity environment broadly followed national guidance, and the service had facilities intended to meet the needs of women, birthing people, and their families.

At the last assessment, we were concerned about the estate, environment and equipment. Although there had been some refurbishment in some areas such as painting of the maternity assessment unit, refurbishment and improvement works were still on-going or planned for the birth centre and maternity triage.

At the time of the assessment, the birth centre was undergoing refurbishment of 2 birthing rooms with plans to change the birthing pools. Although the birth centre had 3 birthing pools located within the labour ward, 1 birthing pool had been condemned due to damage, and replacement pools, while approved, were still pending installation at the time of our assessment. This may limit choice for women and birthing people. Post assessment, the trust provided evidence which showed the reduced capacity of the birthing pool did not impact in limiting the choice for women. The service had better rates of women who accessed the birth centre compared to the national average. The birth centre corridor was also due for refurbishment with a plan date of completion of the end of March 2026. The service also planned to refurbish 9 bathrooms on the maternity wards.

The maternity triage estate work was planned for 2025/2026. During our assessment we observed work was taking place to convert a bathroom on the labour ward into a triage initial assessment room and private consultation area. This would help staff have private conversations with women, to maintain their privacy and dignity as the current triage bay area had 3 beds with no private space. Staff told us that whilst waiting for this work to be completed they used a room in the birth centre or labour ward, which was co-located in the areas to have private conversations.

During the assessment, the maternity environment did not consistently meet expected safety standards, and several environmental risks required improvement such as pest control and water quality. Inspectors observed that the estate was significantly aged which contributed to visible deterioration such as damaged walls and paintwork.

During the assessment, staff on the maternity wards told us there have been recent incidents of mice seen on the ward, which was escalated and reported as an incident. This resulted in a pest control team sanitising the ward and sealing some cracks to avoid reoccurrence. Although pest‑control measures were reinforced, this was an ongoing risk due to the integrity of the estate and the reliability of the environmental controls. The risk register included risk about the general environmental issue of the service due to the aged estate however there was no specific concerns, actions or mitigation around pest control.

Environmental safety showed on-going improvement in relation to ongoing water issues in inpatient areas. The service had identified water quality safety issues in 2024 and had received support from the estates team to resolve the issue. This resulted in the installation of tap filters in the service to maintain water safety, and a portable sink being added in a room on the antenatal ward. The water had been tested for pseudomonas and legionella and was considered safe. The service planned on changing the water pipes in the future and a full tap replacement was not scheduled until December 2025 to January 2026, meaning these risks had not yet been fully resolved. To mitigate the risk, staff told us they carried out daily water tests to ensure its safety.

Despite the issues found at our assessment, it was identified that the condition, age of the estate and design followed national guidance, and facilities were intended to meet the needs of women and their families. Clinical areas were generally clean, and daily cleaning audits were in place, with staff maintaining high standards of internal cleanliness despite external deterioration. Patient feedback reflected this contrast, noting the outside environment as “dreadful” but describing the inside as “decent,” demonstrating the commitment of staff to maintain safe environments within clinical spaces.

Birthing partners were welcomed and supported to attend births and provide care and reassurance to women across all areas of the service. The service had suitable facilities to meet the needs of women's families. In the event of a fetal loss, the service offered bereavement facilities to support families. The bereavement room now had a separate entrance and was sound proofed to enhance bereaved families experience, dignity and privacy. This was an improvement from the last assessment.

Maternity theatres had temporarily been refurbished and remained operational. The trust had introduced elective obstetric “twilight sessions” to increase capacity and manage rising caesarean section activity, demonstrating proactive planning to maintain access and safety.

Emergency and routine equipment, including cardiotocographs (CTG), sonicaids and neonatal resuscitaires were available and appropriately maintained. Audit data showed compliance with environmental and equipment checks: of equipment such as the adult resuscitation trolley, resuscitaires, the milk fridge. Fridge‑temperature monitoring ranged from 94% to 100% across the maternity unit at St Helier between July and November 2025. The majority of the equipment checks were completed daily by staff, however; we observed some gaps in theatres and postnatal wards.Inspectors also found the formula milk fridge unlocked, presenting an increased risk of contamination, theft and access to sterilised facilities. This was escalated and resolved promptly, but it highlighted inconsistencies in routine environment and equipment checks.

Leadership demonstrated an awareness of environmental pressures and had plans in place, such as the scheduled tap replacement programme, estate plan and refurbishment work and the commissioning of new birthing pools to address outstanding risks and improve the overall physical environment.

Women and birthing people were able to reach call bells, and staff responded promptly. Inspectors observed safe management of clinical waste, with sharps bins being used within safe limits. Waste segregation was also in line with the trust’s policy.

The service did not always make sure there were enough qualified, skilled and experienced staff. However, managers ensured staff received effective support, supervision and development. Staff worked well together to provide safe care that met people’s individual needs.

The service monitored maternity staffing incidents classified as ‘red flags’ in line with the NICE guideline: Safe Midwifery Staffing for Maternity Settings. A midwifery ‘red flag’ indicates a potential issue with staffing levels. Between September 2024 and February 2025, 35 red flag events were reported, mostly relating to admission for induction and the beginning of the process (17%), delayed or cancelled critical activity (6%), delay between presentation and triage (6%) and labour ward supernumerary status (3%). Managers monitored red flags and took actions such as redeployment of staff and launching an induction of labour quality improvement projects to improve safety. To meet elective caesarean demand and reduce delays in procedures, the service had introduced an ad-hoc Friday list. Staff told us the additional list helped reduce delays and improved women’s experience. During our assessment, we observed the band 7 coordinators maintained their supernumerary status throughout their shift.

During the assessment the numbers of midwives, maternity support workers, and medical staff did not always match the planned staffing levels in all areas. On the second day of the assessment, we saw that the rota had gaps of 1 midwife and 1 maternity support worker. Senior midwives told us this was due to staff calling in sick and they would use bank staff to cover the gaps.

The home birth service had recently been reconfigured following staff consultation and recruitment. However, the service experienced challenges covering the on-call rota at night. The rota for the period 3 November to 2 December 2025, showed 60% of night on call shifts did not have an allocated staff name. Also, the on-call rota for the 3 to 14 December had 50% gaps in night cover. Staff told us managers would try to fill such gaps in the rota with temporary staff when needed. This meant that during nights without on-call cover, the service would not be able to accommodate all women who had requested a homebirth and went into labour. In such situation, the women would be required to come to the hospital to give birth. Concerns about maternity staffing and their workload was reflected in the staff survey. Data showed only 39% of staff felt there were enough colleagues to perform their job properly.

The service had several structured systems in place to support staffing management. The service used the OPEL framework to measure operational pressures and used the Birthrate Plus acuity tool to calculate the number of midwives needed on the maternity unit. The Midwife in charge carried out the calculation every 4 hours. The service also held twice daily safety huddles to monitor staffing and acuity and redeployed staff to other areas based on acuity when needed.

The service had an escalation policy which clearly defined escalation levels, contingency arrangements and the process for cross‑site redeployment of staff. Staff reported feeling confident to escalate staffing concerns, and these were routinely discussed during handovers and briefings.

Audit data showed that midwifery fill rates averaged 92% over the previous 6 months, which was slightly below the trust target of 94%, and adequate cover was achieved through bank and agency staff.

The service had a good skill mix of medical staff on each shift, which was reviewed regularly, and data showed 100% fill rate. The anaesthetic rota complied with Anaesthesia Clinical Services Accreditation standard 1.7.2.1, and the maternity service had a dedicated anaesthetist available 24 hours a day, 7 days a week to cover the labour ward for elective and emergency caesarean sections.

The service reported an over establishment of medical staff. However, the service challenges for medical staff were around managing the clinical availability of consultants due to programmed activity (PA) reductions, their lead roles, and the clinical capacity of resident doctors to meet clinical demand. Although registrar turnover continued to challenge medical staffing stability, recruitment activity demonstrated progress. The service reported recruiting 17 new starters and had 7 leavers between May and October 2025. Medical staff expressed appreciation for the open‑door approach of managers and felt supported in raising concerns, which helped mitigate some pressures associated with workload. Staff told us the service was reviewing medical staffs’ workload, rotas and clinical activity to improve staffing and service provision. However, the service always had an obstetric and anaesthetic consultant on call during evenings and weekends. The service achieved 100% compliance with RCOG audit of consultant presence on the labour ward. The General Medical Council National Trainee Survey (GMC NTS) 2025 survey results showed that 88% of specialty trainees in obstetrics and gynaecology responded that they would rate the quality of clinical supervision out of hours as excellent and good.

The practice development team provided and monitored mandatory training for midwifery and medical staff. Overall compliance for statutory mandatory training was 85% for all staff, which met the trust target of 85%. However, there was low compliance in individual training. Compliance for adults’ resuscitation level 1-3, which was part of the statutory mandatory training was only 72%. However, the service provided practical obstetric multi-professional training (PROMPT) which involved a session on maternal collapse, escalation and resuscitation. Actions were in place to improve compliance by booking staff for upcoming training sessions and sending reminders.

The overall compliance for the maternity specific training for midwives and maternity support workers was 94% excluding newly introduced training, and 94% for medical staff. Both of which exceeded the service target of 90%. A new maternity essentials study day had been introduced to strengthen core competencies following areas of improvement identified from learning from incidents and training gap analysis.

The Saving Babies’ Lives care bundle was fully implemented, with over 90% of staff trained, demonstrating compliance with national safety standards. Audit results also showed compliance with fetal monitoring annual training and competency, exceeding 94% across all staff groups.

It was identified at the last inspection that staff supporting women following a caesarean section had not been trained to the same standard as for all recovery practitioners working in other areas of general surgical work. The service now had a full multidisciplinary team for maternity theatres, with a separate team for emergency and elective list procedures including a theatre nurse for scrubbing. The service now had fully trained recovery nurses and midwives with high dependency unit experience working within maternity. This was an improvement from the last inspection. The service now had a lead midwife enhanced maternity care (EMC) who oversaw specialised care for women who required closer monitoring. However, the EMC lead worked 30 hours a week and was not available to work on every shift. This was not fully in line with the Intensive Care Society 2023 Enhanced Maternal Care Units guideline, which advised that EMC trained staff should be on every shift to provide leadership and coordination. It was unclear if there were plans to address this gap at the time of the assessment.

At the last inspection, it was identified that the transitional care bay was staffed by a maternity support worker and midwife with no additional neonatal training and no neonatal nurse present, which was not in line with British Association of Perinatal Medicine (BAPM) guidance. In response the service launched a transitional care model and quality improvement (QI) project to comply with national standards. The model and QI project had involved recruitment of neonatal nurses for the unit, training and competency assessment of neonatal nurses, support workers and midwives. At this assessment, the transitional care bay was managed by a band 7 and staffed by a neonatal nurse, maternity or neonatal support worker and a midwife on each shift. This enabled babies to remain with their mothers and minimise separation by reducing admission and length of stay to the neonatal unit.

Staff told us this had improved staffing and service provision and significantly reduced the number of neonatal transfers to the neonatal unit by approximately 70 a month. The November 2025 trust board papers also showed that the transitional care plan had resulted in a 90% reduction in transfers to the neonatal unit.

Managers supported staff to develop through yearly, constructive appraisals of their work. Appraisal data showed 99% compliance for midwifery staff and 92% compliance for medical staff against a trust target of 90%. This was an improvement from the last assessment.

The trust had implemented a structured recruitment process led by the PDMs to promote fairness and strengthen workforce sustainability. Newly qualified midwives were supported through established preceptorship programmes, and internationally educated midwives received additional assistance through orientation and competency frameworks. This helped provide structure and a supportive transition from being a student and an internationally trained midwife to being a competent, autonomous and confident professionals.

The service assessed and managed the risk of infection. However, not all staff complied with the uniform policy and were up to date with the Fit Testing for Personal Protective Equipment.

The service demonstrated compliance in some areas of infection prevention and control expectations. All ward areas were visibly clean, well‑maintained and appropriately furnished, supporting a safe and hygienic clinical environment. Cleaning records were up to date, with evidence of daily cleaning audits and weekly audits where actions were completed promptly. Inspectors observed that 97%–100% of daily and weekly cleaning checks were completed on the labour ward during October and November 2025, confirming consistency in environmental monitoring.

Audit data demonstrated cleanliness compliance of 100% across maternity areas from September to November 2025, which aligned with national hygiene standards and was supported by strong Patient‑Led Assessments of the Care Environment (PLACE) scores.

Staff maintained equipment well, with ‘I am clean’ stickers clearly displayed and in date following decontamination. Staff adhered to IPC principles, including effective handwashing and appropriate use of PPE. Hand hygiene audits showed 99% compliance indicating good general practice.

Mandatory IPC training compliance exceeded expectations, with 98%–99% of staff up to date, above the trust target of 90%. The service met Control of Substances Hazardous to Health (COSHH) requirements, demonstrating safe storage and handling of hazardous materials and cleaning agents.

The service provided training for Fit testing (FIT) for Personal Protective Equipment (PPE), such as FFP3 respirators, which are PPE masks that provide the highest level of protection from breathing air pollution and are used during higher risk clinical tasks. However, staff training compliance had declined. The trust did not provide figures for the FIT PPE training; however, the September 2025 infection prevention and control report stated there had been a decline in staff training compliance.

During the assessment, we observed most staff complied with the uniform policy however we observed 2 members of staff were wearing dangly and hoop earrings. This increased the risk of infection to women and staff. This was not in line with trust policy and best practice. The decline in FIT compliance and poor adherence to uniform standards, highlighted areas where practice deviated from expected infection‑control standards and required strengthened oversight to maintain safety.

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

The service demonstrated compliance with medicines management standards and practices. Staff followed good practice in medicines management, including transport, storage, dispensing, administration, medicines reconciliation, recording, and disposal, in line with national guidance and local policy. Medicines were stored securely in locked clinical rooms, with controlled drug cupboards and keys managed appropriately. Controlled drug audits were completed as per policy, and registers were maintained in line with legal requirements. Spot checks confirmed compliance, and any discrepancies, such as index page entries not being up to date in the controlled drug register, were promptly rectified.

Daily checks of room and fridge temperatures were completed, with fridges maintained within the required range of 2–8°C and room temperatures below 25°C. Compliance with temperature monitoring was 100% during the assessment period. Emergency medicines were available and checked twice daily, with audit data showing 99% compliance across all areas. Medical gases, such as oxygen cylinders, were stored safely with correct signage, and empty cylinders were segregated. Waste medicines awaiting destruction were stored securely in designated bins labelled with opening dates and location.

Staff followed systems and processes to prescribe and administer medicines safely. Prescribing was undertaken by doctors using the electronic prescribing and medicines administration (EPMA) system. Allergy status was clearly documented in patient EPMA records and highlighted using red wristbands. Midwives were able to administer medicines under exemption provisions.

Medicines reconciliation was carried out on admission in most cases, with audit data showing 95% compliance for reconciliation within the required timeframe. Discharge processes were supported by the availability of pre-prepared To Take Away (TTA) packs to avoid delays. Where additional medicines were required, such as extended courses of anticoagulant medication, staff liaised promptly with pharmacy services.

Women were appropriately involved in decisions about their medicines. Staff provided counselling on side effects and treatment plans, supported by patient information leaflets. Pharmacists were available on-site and via an out-of-hours on-call service to provide advice and review prescriptions, including as required medicines. Staff demonstrated an awareness of relevant reference materials and local policies, ensuring safe prescribing and administration. Medicine records were completed accurately and kept up to date, with audit data confirming 100% compliance for documentation accuracy.

Medicine incidents were discussed regularly at departmental meetings, and learning was shared trust-wide with pharmacy support. Staff also acted on safety alerts and incorporated lessons learned into practice. Audit data confirmed that 100% of safety alerts were actioned within required timeframes.