Queen Elizabeth The Queen Mother 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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked if women were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked women’s liberty was protected where this was in their best interests and in line with legislation.

At our last inspection we rated this key question inadequate. At this inspection the rating changed to requires improvement. Women were safe and protected from avoidable harm however, the constraints of the physical environment meant the team could not mitigate for the unavoidable separation of mothers and babies in situations where babies required resuscitation following birth.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a positive culture focused on safety, based on openness and honesty. Staff listened to concerns about safety, reported and investigated safety events. Lessons were learnt to continually identify and embed good practice.

Staff knew what incidents to report and told us how they reported them. Staff raised concerns and reported incidents and near misses in line with the trust policy. Staff we spoke with could describe what incidents were reportable and how to use the electronic reporting system. Leaders provided feedback on learning from incidents via email, meetings and newsletters. We saw themes and trends from learning were shared at handovers and safety briefings. During the safety huddles which staff attended, there was a maternity message of the week.

Leaders reviewed incidents on a regular basis so they could identify immediate actions to take. We saw evidence of changes having been made following learning from reported incidents. Recently the service found there was a low uptake in vaccinations. In response to this vaccinations were routinely offered during antenatal appointments and records showed they had been an increase in women having vaccinations.

Urgent issues were reviewed by the governance team as part of a rapid review. They identified any urgent risks and actions which could be put in place to reduce the risk to women and babies going forward.

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

Staff of all grades attended regular safety huddles during their shift. This was an opportunity to share safety information. At the change of shift the medical and midwifery teams had handover meetings to discuss all women within the maternity unit. During the inspection we attended several handover meetings and safety huddles. We found them well attended and used to fully discuss the patients and concerns. There was a regular homebirth huddle, where staff discussed the progress and safety of current women having a home birth. This huddle also discussed any women who planned to birth outside of national guidance.

There was a cross site daily status (sitrep) meeting, which we attended during the inspection. The meeting was chaired by the head or director of midwifery and ran to a set agenda. The agenda covered both sites of the hospital and included for example: staffing, bed capacity and learning from recent incidents. The director of midwifery chaired a weekly ‘stop the clock’ meeting. Attending staff discussed any risks related to environmental audits, which included for example, infection prevention and control, cleaning of birthing pools and equipment safety checks. They also discussed audit related to the safety of women. A live action plan for each area of focus and the level of risk was used to monitor standards. At the time of inspection 87% of planned actions had been achieved.

The medical team had a daily board round where they discussed the care and treatment of women in their care. We attended a board round during the inspection and saw the discussion focused on the safety of women and babies.

Women’s notes were clear, and all staff could access them easily. Staff used both paper and electronic notes with critical information duplicated in both. Paper notes were used at antenatal appointments. We reviewed 8 patient records and found them to be detailed and completed correctly by all grades of staff. Staff added to the records in real time so any health professional accessing the notes had the most up to date information about the person. Records were stored securely. All computers were password protected, and staff locked the terminals when not in use.

The department had recently installed an electronic patient tracking system. This flagged patients attending the hospital who may have needed support from the maternity team. We saw a pregnant woman had booked into the accident and emergency department and a midwife immediately contacted the emergency department to offer support in managing the care of this patient. Staff told us this initiative had been shortlisted for a Royal College of Midwives Award.

Transitional care was provided in the nearby special care baby unit (SCBU). Transitional care is an area within a maternity ward where newborns who need a little extra care beyond routine monitoring are cared for alongside their mothers, allowing for a smooth transition from delivery to going home. There was a close relationship between the staff working in the SCBU and maternity unit. All babies who needed special care or transitional care were discussed at an Avoiding Term Admissions into Neonatal Units (ATAIN) meeting. An ATAIN meeting focuses on reducing unnecessary admissions of full-term babies to neonatal units by identifying and addressing potential issues. This may include for example, breathing problems, low blood sugar, and jaundice, thereby promoting better mother-baby bonding by keeping them together as much as possible. The ATAIN meeting was well attended by the multidisciplinary team and included the fetal monitoring midwife.

There was an infant feeding team who were available to provide support with both breast feeding and formula feeding. They offered mothers one to one support in this area.

Women who were less than 16 weeks pregnant and had concerns about their pregnancy could access care in the early pregnancy unit (EPU) which was situated on the maternity unit. The EPU was open between 7am and 4pm Monday to Friday and alternate Saturday and Sunday. On occasion women, less than 16 weeks pregnant, would attend the emergency department and be referred to the gynaecology team or the early pregnancy unit when it was open. Staff told us this pathway was not always followed as not all emergency department staff were aware they could refer to the EPU. Staff told us they had funding for a bereavement room for early pregnancy loss.

The service worked with women and healthcare partners to understand what being safe meant to them and the best way to achieve this. Staff 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.

Staff received training specific for their role on how to recognise and report abuse. Records showed 93.7% of midwives had received level 3 safeguarding training. This was in line with national guidance for clinical staff caring for adults and children. Figures were lower for the wider team; only 75% had received Level 3 safeguarding training. However, senior leaders had a plan to improve compliance by March 2025 and we saw evidence to confirm that as of March 2025 overall compliance was 89.1%. Midwives asked women about domestic abuse and recorded this on the electronic patient notes system.

Staff, from all areas within the maternity unit, we spoke with during the inspection could identify what constituted abuse and how to report their concerns to the safeguarding team. The trust had recently recruited a senior safeguarding lead midwife who would have oversite of safeguarding procedures across both hospital sites. The safeguarding team were available office hours during the week. Staff told us they were very supportive and responsive when contacted. The safeguarding team completeda weekly ward round to review women and support with any safeguarding concerns staff had. The safeguarding team also attended the daily Situation Report Meetings (SitRep meetings).

There was a baby abduction policy and staff undertook baby abduction drills, so they knew what to do in the event of an attempted baby abduction. The last drill was approximately 2 months before the inspection. Access to all areas was strictly controlled. Staff with authority to enter had a token they could use to unlock doors. All other visitors used a video camera doorbell to alert staff they needed to enter. We saw ‘tail gating’ (when a person tried to enter with another person who had permission to enter or exit the area) was not permitted and all staff challenged unauthorised persons.

Staff could give examples of how to protect women from harassment and discrimination including those with protected characteristics under the Equality Act. Staff understood the importance of supporting equality and diversity and ensured care and treatment was provided in accordance with the act.

The service did detect and control potential risks in the care environment. Staff made sure equipment, facilities and technology supported the delivery of safe care. The design of the environment was compliant with national guidance apart from the labour ward and maternity theatres. The labour ward rooms were too small, hot and were not en-suite.

The whole maternity unit was clean, tidy and free of clutter. Fire exits were clearly marked and unobstructed. Efforts had been made to consider patient area space and utilisation. The midwifery led unit (MLU) was an excellent example of this and rooms had minimal medical equipment and were welcoming and comfortable. The MLU had a ‘nest room’ for women in early labour. There was a double bed for the woman and her partner to lie on together, dimmed lighting, light projectors and the ability to stream music of choice.

The maternity unit included triage, antenatal clinics, midwifery led unit, ward area, labour ward, labour theatre, recovery area and a bereavement suite. The unit was fully secure with a monitored entry and exit system, which we saw during our visit. There was a ward clerk for the whole unit between 7.30am and 8.30pm and overnight there was a ward clerk on the labour ward between 8pm and 8am.

There was only one dedicated obstetric theatre which was not in line with national guidance which required two obstetric theatres to be available. This risk was noted on the risk register and the hospital had a plan to re-build the maternity department in 2025. The planned re-build included a second obstetric theatre.

The labour ward had 7 small rooms which could become quite hot, 1 of the rooms had been repurposed as a resuscitation room and 1 room had a birthing pool. There were 6 infant resuscitaires in the labour ward. They were located in the pool room, 2 of the labour rooms, the clinical room and theatre recovery. There was a dedicated resuscitation room. Labour rooms were too small to accommodate essential equipment which included infant resuscitaires. This had been the focus of a quality improvement project to ensure this risk was mitigated. Leaders told us these risk assessments were completely embedded to ensure this process was safe and staff completed regular drills to ensure they were familiar with the process. However, they could not mitigate for the unavoidable separation of mothers and babies in situations where babies required resuscitation following birth.

Patient toilets were shared between 2 labour rooms using a Jack and Jill door system. Leaders were aware of the difficulties with the current layout and told us of plans to reconfigure and upgrade the labour ward.

The rooms in the labour ward did not have piped gas and air and a cylinder had to be brought into the room for women to use during labour. Staff were at risk of workplace exposure to gas and air and were required to have regular blood tests for their safety. This risk had been reduced by the installation of a gas scavenging unit, which was in line with national guidance.

The labour rooms became very hot and did not have air conditioning, unlike the resuscitation room. On the day of inspection, we saw 1 of the labour room doors remained open with a screen round the open door. The screen was used to try and maintain the privacy of the woman in labour, whilst cooling the temperature. Staff told us the labour rooms were too small to provide care and monitoring to the person in labour and this was the only solution. This risk was noted on the risk register and the hospital had a plan to re-build the maternity department in 2025.

There was a separate room where women admitted for induction of labour were cared for until they were in established labour.

Women who underwent a planned caesarean section were admitted to the antenatal ward. The journey from the ward to the operating theatre passed through cold corridors and a quality improvement project had developed a project to prevent babies from suffering from hypothermia during this journey. Heated cots, towels and blankets were used to transport the newborn baby back to the post-natal ward.

Since the last inspection the team had created a neonatal room. This room was a dedicated paediatric space to support completing the required Newborn and Infant Physical Examination (NIPE) checks. These checks are a physical screening of a baby's eyes, heart, hips, and testes and are completed before discharging the baby after birth. There was a newborn care coordinator in post who organised NIPE checks for those babies who needed them.

Staff completed daily checks of specialist equipment. Records showed these checks had been consistently completed for the 3 months before the inspection. Baby resuscitation equipment on the labour ward was checked daily. Checks on the adult resuscitation and emergency trolleys were fully completed.

Senior midwives completed monthly environmental and patient care audits and checked if staff completed important safety tasks. The results of the audits were used to identify areas for improvement and assure the leaders the maternity unit was safe. The unit had been risk assessed for ligature risks and there was a ligature cutter on the emergency equipment trolley.

Staff disposed of clinical waste safely. Contaminated waste was segregated correctly and stored securely while awaiting disposal. Sharps bins were assembled correctly and not over filled.

On the post-natal ward, we observed the ward office door was wedged open even though it had a coded lock and contained confidential patient information and was a fire door. We spoke to staff at the time, and they told us it was not a risk as staff were in the room all of the time.

The unit had a bereavement area where women and families could spend time after delivering a baby who was still born. It had been developed as a quality improvement project to improve the experience of bereaved parents and there was a fulltime bereavement midwife in post. The bereavement area had a dedicated parking space and direct access without needing to enter the maternity unit. There was an outdoor area for their use and a memorial mural on the wall. The area had specialist equipment such as cold cots, which would allow the family to spend several days with their baby after birth. Families were supported to wash, dress and care for their baby. There was the opportunity for photographs and to take foot and handprints before they had to say goodbye. Specific memorial products for women with religious beliefs were provided. The service offered bereaved families the opportunity to attend an annual memorial service at Canterbury Cathedral. The bereavement midwife and the team had been nominated for and won several awards including ‘Special Recognition – Bereavement Midwife of the Year’ and ‘Specialist Midwife of the Year ‘.

The service did detect and control potential risks in the care environment. Staff made sure equipment, facilities and technology supported the delivery of safe care. The design of the environment was compliant with national guidance apart from the labour ward and maternity theatres. The labour ward rooms were too small, hot and were not en-suite.

The whole maternity unit was clean, tidy and free of clutter. Fire exits were clearly marked and unobstructed. Efforts had been made to consider patient area space and utilisation. The midwifery led unit (MLU) was an excellent example of this and rooms had minimal medical equipment and were welcoming and comfortable. The MLU had a ‘nest room’ for women in early labour. There was a double bed for the woman and her partner to lie on together, dimmed lighting, light projectors and the ability to stream music of choice.

The maternity unit included triage, antenatal clinics, midwifery led unit, ward area, labour ward, labour theatre, recovery area and a bereavement suite. The unit was fully secure with a monitored entry and exit system, which we saw during our visit. There was a ward clerk for the whole unit between 7.30am and 8.30pm and overnight there was a ward clerk on the labour ward between 8pm and 8am.

There was only 1 dedicated obstetric theatre which was not in line with national guidance which required 2 obstetric theatres to be available.This risk was recorded on the risk register and during the factual accuracy process leaders confirmed their planning of a new build maternity department was starting during 2025.

The labour ward had 7 small rooms which could become quite hot. One of the rooms had been repurposed as a resuscitation room and 1 room had a birthing pool. There were 6 infant resuscitaires in the labour ward. They were located in the pool room, 2 of the labour rooms, the clinical room and theatre recovery. There was a dedicated resuscitation room. Labour rooms were too small to accommodate essential equipment which included infant resuscitaires. This had been the focus of a quality improvement project to ensure this risk was mitigated. Leaders told us these risk assessments were completely embedded to ensure this process was safe and staff completed regular drills to ensure they were familiar with the process. However, they could not mitigate for the unavoidable separation of mothers and babies in situations where babies required resuscitation following birth.

Patient toilets were shared between 2 labour rooms using a Jack and Jill door system. Leaders were aware of the difficulties with the current layout and told us of plans to reconfigure and upgrade the labour ward.

The rooms in the labour ward did not have piped gas and air and a cylinder had to be brought into the room for women to use during labour. Staff were at risk of workplace exposure to gas and air and were required to have regular blood tests for their safety. This risk had been reduced by the installation of a gas scavenging unit, which was in line with national guidance.

The labour rooms became very hot and did not have air conditioning, unlike the resuscitation room. On the day of inspection, we saw 1 of the labour room doors remained open with a screen round the open door. The screen was used to try and maintain the privacy of the woman in labour, whilst cooling the temperature. Staff told us the labour rooms were too small to provide care and monitoring of the woman in labour and this was the only solution.This risk was noted on the risk register and leaders confirmed (during the factual accuracy process) that they were starting to plan their new build maternity department during 2025.

There was a separate room where women admitted for induction of labour were cared for until they were in established labour.

Women who underwent a planned caesarean section were admitted to the antenatal ward. The journey from the ward to the operating theatre passed through cold corridors and a quality improvement project had developed a project to prevent babies from suffering from hypothermia during this journey. Heated cots, towels and blankets were used to transport the newborn baby back to the post-natal ward.

Since the last inspection the team had created a neonatal room. This room was a dedicated paediatric space to support completing the required Newborn and Infant Physical Examination (NIPE) checks. These checks are a physical screening of a baby's eyes, heart, hips, and testes and are completed before discharging the baby after birth. There was a newborn care coordinator in post who organised NIPE checks for those babies who needed them.

Staff completed daily checks of specialist equipment. Records showed these checks had been consistently completed for the 3 months before the inspection. Baby resuscitation equipment on the labour ward was checked daily. Checks on the adult resuscitation and emergency trolleys were fully completed.

Senior midwives completed monthly environmental and patient care audits and checked if staff completed important safety tasks. The results of the audits were used to identify areas for improvement and assure the leaders the maternity unit was safe. The unit had been risk assessed for ligature risks and there was a ligature cutter on the emergency equipment trolley.

Staff disposed of clinical waste safely. Contaminated waste was segregated correctly and stored securely while awaiting disposal. Sharps bins were assembled correctly and not over filled.

On the post-natal ward, we observed the ward office door was wedged open even though it had a coded lock and contained confidential patient information and was a fire door. We spoke to staff at the time, and they told us it was not a risk as staff were in the room all of the time.

The unit had a bereavement area where women and families could spend time after delivering a baby who was still born. It had been developed as a quality improvement project to improve the experience of bereaved parents and there was a fulltime bereavement midwife in post. The bereavement area had a dedicated parking space and direct access without needing to enter the maternity unit. There was an outdoor area for their use and a memorial mural on the wall. The area had specialist equipment such as cold cots, which would allow the family to spend several days with their baby after birth. Families were supported to wash, dress and care for their baby. There was the opportunity for photographs and to take foot and handprints before they had to say goodbye. Specific memorial products for women with religious beliefs were provided. The service offered bereaved families the opportunity to attend an annual memorial service at Canterbury Cathedral. The bereavement midwife and the team had been nominated for and won several awards including ‘Special Recognition – Bereavement Midwife of the Year’ and ‘Specialist Midwife of the Year ‘.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked well together to provide safe care which met women’s individual needs.

Managers accurately calculated and reviewed the number and grade of midwives and maternity support workers needed for each shift in accordance with national guidance. Staffing was monitored by senior managers at daily, online cross site meetings. A maternity safe staff workforce review was last completed in October 2024.

The service had a recruitment and retention strategy to keep staffing under review.

There was at least 1 supernumerary shift coordinator on duty at any time who had oversight of staffing. There were enough resources to adjust the staffing levels according to the current number of women in clinical areas. Staff told us they were qualified and happy to work in each area of the maternity unit.

The service a 6.56 % vacancy rate for midwives. Data showed the vacancy rates were highest in band 6 midwives. The current Band 5 vacant posts were expected to be filled by student midwives who were about to qualify and had their student placements in the unit. To cover unfilled shifts the trust used bank staff. Managers requested bank staff who were familiar with the service and ensured they had a full induction and orientation of the area they were working in.

The sickness rate for midwifery staff was 6.5 percent. The service had a low turnover rate of 2.3 percent.

The service ensured all staff were competent for their roles. Managers appraised staff performance and held supervision meetings, providing support and development. The appraisal rate for the maternity service was 80.5%, meeting the target. Newly qualified midwives had a 12-to-18-month preceptorship program, which supported them to transition from student to qualified midwives.

The service had enough medical staff to keep women and their babies safe. The medical staff matched the plan number. The service had 16 consultant obstetricians and there was always a consultant on site. However, there were three vacant Consultant Obstetrician posts, and a recent recruitment campaign had been unsuccessful. This was noted as a risk on the risk register. The consultant obstetricians working pattern was 8am to 5pm day shift, 5pm to 10pm twilight shift and a night shift on call in the hospital. There was always a dedicated emergency caesarean section team available. Consultants of different specialities such as anaesthetists, obstetricians and neonatologists had regularly study days as a team and they told us this had worked well to break down barriers and improve relationships.

The service had a good skill mix and availability of medical staff on each shift and managers reviewed this regularly.

The fill rate of most shifts was 85.5 percent. Managers could access locum doctors when they needed additional medical staff and ensured locum doctors had a full induction and orientation of clinical areas before they started work.

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

All areas in maternity were clean and had suitable furnishings which were visibly clean and well maintained. Cleaning records were up to date and showed all areas were cleaned regularly. Records we reviewed showed the cleaning standards for the last 3 months had been met. Staff cleaned equipment after contact with women. Staff used ‘I am clean’ stickers to show equipment was clean and ready for use.

Matrons oversaw infection prevention and control across the maternity department. Staff followed infection prevention and control principles and included the use of personal protective equipment (PPE). All staff were bare below the elbow, and we observed staff washing their hands or decontaminating them with antibacterial hand gel. All visitors to the maternity department were prompted to decontaminate their hands on entering the department. On the day of inspection, we saw all PPE dispensers were fully stocked, and PPE was consistently used by staff.

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

The trust used a paper-based system to prescribe and record administration of medicines. There were policies and procedures to support the safe and effective use of medicines including the management of post-partum haemorrhaging. (bleeding after the baby's delivery) Staff issued ‘to take out’ packs to speed up discharges. However, there was no oversight of the quantities of each that should be held on the wards and when they had been used.

Staff administered medicines safely to women on the maternity wards. Medicines were stored safely and securely in temperature-controlled rooms. However, flammable medicines had not always been stored in a flame-resistant cupboard. We saw the medicines room door was not always kept closed on Kingsgate ward. Prescription pads were stored safely. Checks ensured prescriptions could be tracked once issued.

Staff were suitably trained to administer medicines with bespoke training being offered to support staff to manage conditions such as diabetes more effectively. A pharmacist visited the ward daily and staff we spoke too said they valued the expert advice available from the pharmacy team. The Trust employed an infant feeding team who worked with the pharmacy team when considering how prescribed medicines could affect a person when breastfeeding. Staff had identified medicines were sometimes not given when women had gone outside of the ward during medicines round times. To reduce this from happening, cards written in multiple languages and left on beds reminded women to find their midwife to get their prescribed medicines on their return. Staff said they were able to raise any concerns and ask for support and felt there was a good working relationship between midwives, managers and consultants.

Women were supported to receive their medicines in a timely and effective way. Risks identified during a person’s pregnancy were managed effectively, this included where medicines had the potential to cause withdrawal in a newborn baby or conditions such as diabetes or epilepsy. Staff ensured they understood and considered any cultural needs when supporting women with medicines. One person we spoke with said, “Staff gave ample pain relief and as soon as I asked for it”, and “Staff have been amazing”.The Ward had introduced 4-hourly intentional rounding to review women which included ensuring ample pain relief was offered.