The Tunbridge Wells Hospital at Pembury

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 assessed all 8 quality statements. Safety had improved since our previous inspection, but we still found a breach of safe care and treatment. More work was needed to improve the flow throughout the unit which continued to cause delayed inductions of labour. Obstetric consultants were also required to cover gynaecology and there were staffing shortages within midwifery. This also impacted on flow throughout the unit and could impact on safety. Equipment was not always checked and this included emergency equipment.

However, there was a positive safety culture where incidents were investigated, and learning was embedded to promote good practice and outcomes. Staff were open and honest when things went wrong or could be a risk. We found improvement with training compliance, medicine management and infection prevention and control.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Women and birthing people told us they felt safe, and their maternity care and treatment was explained to them throughout their maternity journey. They told us they were mostly seen and reviewed quickly by midwives and updated and informed about their care.

Staff told us they felt confident to report incidents and were supported to proactively identify and manage risks before safety events occurred. Staff gave examples of how they felt confident and supported to challenge clinical decisions and escalate concerns. This included junior staff and students. They were able to raise concerns through a variety of avenues, including freedom to speak up guardians (FTSUG) and knew how to contact them.

Staff told us incidents and complaints were appropriately investigated and lessons learned were shared within handovers, information boards and staff newsletters. Learning was used to make improvements. For example, the practice development team had introduced workshops for births assisted by forceps. This was in response to an increased incident of post-partum haemorrhage. Staff had changed their practice from estimating blood loss post births to routinely weighing blood loss. This helped identify postpartum haemorrhage more accurately. There was a culture of learning, improvement and supporting families and colleagues.

There was a system to investigate incidents and identify learning. Incidents were reviewed daily and involved a collaborative approach, between the risk, governance and patient safety team. The team reviewed incident content and grading. Incidents that required immediate attention were prioritised to ensure potential safety concerns were addressed and mitigated.

Learning was presented weekly to the Trust Learning Response Review Panel to update them on findings, learning and improvement actions. Learning was disseminated to staff during handovers, safety huddles, staff newsletters, notice boards and formed part of skills and drills and mandatory training.

We reviewed feedback from the CQC maternity survey (2024). We received feedback from 196 women who given birth at the trust and 8.7/ 10 felt their concerns were taken seriously. This was better than the national average for other trusts and women and birthing people that we spoke with told us they were informed of their planned care and treatment.

We attended staff handovers and found key information was shared. Staff used the Situation, Background, Assessment, Recommendation (SBAR) approach. Each area used a different tool to document them. Handovers were structured but lacked standardisation and the process was not embedded.

The trust shared their most recent audit of SBAR compliance. This was completed in June 2024 and highlighted gaps with SBAR standards and documentation. Leaders told us staff received reminders about compliance, and they were working with the Kent, Surrey and Sussex Innovation Team to formulate a standardised SBAR handover tool.

Staff told us they escalated clinical concerns, delayed transfers and discharges to the care flow coordinator (CFC). They stated CFCs and duty managers were visible and responsive. Leaders told us the midwife manning the maternity triage phone line used a recently developed risk assessment for calls relating to newborn babies. The tool was being piloted at the time of our assessment and was used to support decisions for place of referral or admission.

Records were a mixture of paper and electronic which created risk. This meant staff had to duplicate some documentation from paper to electronic records. The audit of compliance for timing of emergency caesarean sections identified that some errors occurred when recording decision times and re-entering the information from paper to electronic records. However, this risk had been on the trust-wide risk register since 2017 and was added to the directorate’s risk register to record local mitigations and action. Leaders told us there plans to replace the maternity information system in 2026.

Leaders told us they worked in partnership with their Local Maternity and Neonatal System (LMNS) to develop a system-wide fetal monitoring strategy. This included updated guidance which reflected national guidance and was rolled out across the LMNS in June 2024. This helped to maintain consistency and the implementation was supported by video and staff communication.

We identified recurrent delays in emergency lower segment caesarean sections (ELSCS) during our previous inspection. A quality group had been established to review the process and identify any barriers or challenges and was led by a consultant obstetrician.

Audit highlighted inconsistencies in the way the decision time was recorded and meant data was not always reliable. A detailed proforma was mandated for each caesarean section (c/s) and included the time the decision was made and the target time for delivery. This supported a thorough review of each case and enabled the team to identify ways to avoid unnecessary delays. Every c/s was added to the maternity dashboard to ensure oversight and continued monitoring. Data collection had improved and there was more effective monitoring and oversight with some improvement in timings of the most urgent c/s (category 1 and 2). Leaders now had a high degree of confidence that the reported data was reliable and accurate.

Waiting times were monitored in triage and displayed on the white board. This included the time women and birthing people presented, assessment and referral times. This was recorded electronically, and we observed the process.

There was a referral process for sonographers to refer women and birthing people following concerns related to ultrasound scans. They could be referred to the day assessment unit or triage, depending on the urgency of the concern. Growth was plotted on electronic gap and grow charts. Leaders told us the new GAP (Growth assessment protocol) 2.0 training programme went live in April 2024. The roll out was prioritised for staff with greatest involvement with GROW with a plan for all relevant staff to receive the training.

Staff followed safe procedures for partners and family visiting the wards. Partners were required to wear a pink wrist band to highlight their suitability to visit. Photos and personal details were distributed if someone was not permitted to visit, and this was shared with security staff too. Access to the wards was by a video entry system and we saw staff checking personal details and for the pink wristband to allow access.

Postnatal staff told us they completed regular baby abduction drills, and the most recent one was 6-8 weeks earlier. All parents and carers were given an information leaflet on baby security with clear instructions on how to keep their baby safe. Families with safeguarding concerns were cared for in rooms nearest to the midwives’ station to support closer monitoring and support.

Maternity services had a safeguarding team which included a named midwife, a deputy named midwife, a safeguarding midwife and administrators. The team had transferred to the corporate safeguarding team in May 2024. They felt this had improved partnership working and sharing of key information and they worked closely with the perinatal mental health team and bereavement team too.

The safeguarding team were focused on supporting staff to develop their knowledge and confidence. Staff told us a member of the safeguarding and perinatal mental health team visited daily to support staff and review care plans. The safeguarding team also operated a duty system where staff could contact them for advice and support. Staff told us they felt well supported with safeguarding matters.

We were told the trust wide safeguarding team were trained to Level 4 for adults and children. Role specific safeguarding training on how to recognise and report abuse had improved since our last visit but was still only 64.3% for midwives for Level 3 safeguarding and 80.3% for consultants, although 90.3% for maternity support workers for safeguarding Level 2 training for adults.

Compliance for safeguarding children Level 3 had improved to 90.4% for midwives, and 83.3% for consultants and 100% for maternity support workers for safeguarding Level 2 training. Overall compliance was 92% for annual maternity updates which included perinatal mental health.

Team leaders and matrons received safeguarding supervision quarterly and midwives received regular supervision when they supported families with safeguarding concerns.

Staff knew how and when to make safeguarding referrals. Safeguarding alerts were recorded as an alert on electronic notes. Referrals were triaged by a multidisciplinary team (based at maternity hubs) and included safeguarding leads, midwives, health visitors, social workers and the perinatal team. Cases were discussed and risk assessed to determine the urgency and level of support required. Staff described effective partnership working.

Staff routinely asked women and birthing people about domestic abuse and recorded it in a mandatory field on the electronic records. Staff used the DASH tool (Domestic Abuse, Stalking, Harassment and Honour Based Violence Assessment) to help determine the risk level when domestic abuse was disclosed. This provided safeguarding professionals with vital information, and we saw the safeguarding team contributed to birth plans when safeguarding concerns were identified.

The safeguarding team had developed a local database to record data specific to women and birthing people who chose to freebirth. This included reasons for choosing to freebirth. Staff wanted to identify themes and trends to provide effective support and recorded public safety information such as birth doulas, who were known to practise illegally.

We noted that safeguarding was included during all handovers, this included a reminder to all staff to book their safeguarding supervision and staff received a safeguarding newsletter every quarter. Overall, there was improved and effective process to safeguard families.

We reviewed results from the CQC maternity survey (2024). We received feedback from 196 women who gave birth at the trust and 8.6 / 10 felt they had been given appropriate information and advice on risks of induced labour. This was similar to the national average for other trusts.

People were informed about risks and how to keep themselves safe. We spoke to 4 women and birthing people during our inspection, who told us they felt listened to, risk was explained, and they were involved in decisions about their care and treatment.

Leaders told us they had focused on improving the process for women and birthing people having an induction of labour (IOL). They had updated their IOL policy and implemented a process called rapid risk assessment for any inductions where transfers were delayed by 2 hours or more (to the labour ward). This involved a clinical review, and the delay was escalated to the care flow coordinator.

The rapid risk assessments helped staff focus on reducing delays and data showed delays had improved. However, staff told us bed blockages frequently occurred on the postnatal ward which affected the flow throughout the unit. On 1 day of our inspection there were 3 mothers and babies who had been discharged but were blocking beds because they were waiting to be collected. However, there were 4 delayed IOL due to bed capacity. This included 2 that were delayed over 24 hours.

Leaders told us they had made some changes to improve flow and discharges. For example, they had implemented discharge coordinators to support with discharge paperwork. However, beds were frequently blocked due to delayed medicines to take home, delayed medical reviews and parents waiting for transport. Leaders told us a project group had reviewed patient flow, particularly on the postnatal ward and there were plans to implement several changes to support more timely discharges.

Leaders had implemented a nationally recognised tool to identify women and birthing people at risk of deterioration. The online tool was known as the Modified Early Obstetric Warning Score (MEOWS) and had been updated to reflect national guidance (the week prior to our visit).

We were told at our previous assessment that MEOWS would be audited as a standalone audit from October 2023. A retrospective audit of 53 births was completed between September and December 2023 and identified gaps in compliance. For example, only 12% of all observations were recorded in full and 10 of the observations should have triggered a doctor review but only 1 was escalated. Recommendations had been made to improve this, which included the roll-out of a new observational MEOWS tool in October 2024 and the implementation of an electronic quality assurance tool (in December 2024) to supported improved monitoring and oversight of MEWS audits. We also reviewed 8 MEOWS records and found staff correctly completed them and had escalated concerns to senior staff.

The last audit of compliance for completion of the Newborn Early Warning Score (NEWS) chart was completed in May 2024. A sample of 16 baby notes were reviewed and showed varied compliance. Seven of the cases should have triggered an escalation but only 2 were escalated. Actions had been developed in response to this audit. This included the implementation of the British Association of Perinatal Medicine NEWTT-2 track and trigger chart by March 2025. However, as part of the factual accuracy process leaders confirmed this action had not been met due to delays in procurement, although the charts were expected by the end of May 2025.

However, leaders had developed a triage tool based on a nationally recognised model. This helped ensure women and birthing people were triaged according to clinical need and urgency. This was an improvement from our previous visit.

Leaders had implemented a nationally recognised tool to identify women and birthing people at risk of deterioration. The online tool was known as the Modified Early Obstetric Warning Score

Women and babies were cared for in environments that were designed to meet their needs. Partners and significant others were supported to attend the birth and provide support through pregnancy, labour and post birth.

We reviewed results from the CQC maternity survey (2024). We received feedback from 196 women who gave birth at the trust and 8.3 /10 felt their partner was involved in care and able to stay with them as much as they wanted. This was similar to results for other trusts.

Staff told us they had enough suitable equipment to care for women and birthing people. For example, the day assessment unit had a scanner and monitoring equipment, there were evacuation nets in pool rooms and there was easy access to emergency equipment in all clinical areas.

The design of the environment followed national guidance. The maternity unit was fully secure with a monitored and locked entry and exit system to different areas and reception areas. Security staff completed walk-arounds every 2 hours and we noted ceiling security cameras in non-patient areas. There were ward clerks at reception desks during normal working hours and emergency buzzers underneath the desks.

There were 15 labour/birth rooms which were spacious, ensuite, with mood-lighting and calming murals on the walls. Two rooms included pools, and every room had facilities to aide labour such as mats and birthing balls. There was enough suitable equipment to care for high and low risk birthing people. Babies who needed a higher level of monitoring were cared for in transitional care cots on the postnatal ward.

There was a 4-bed high dependency bay and 2 obstetric theatres adjacent to the labour ward; 1 was protected for elective caesarean sections and the other was used for emergency caesarean sections. The neonatal unit was close to the labour ward to support quick access when babies needed to transfer.

There was a day assessment unit for planned appointments and a smaller room for elective caesarean section pre-assessments.

Maternity triage consisted of a dedicated waiting area and a 2-bedded bay. There was a single room with a built-in scanner that enabled staff to relay information in a private setting.

Ligature risk assessments had been completed for all clinical areas to protect people at risk from self-harm.

Leaders did not always maintain oversight of equipment to ensure it was safe and ready for use although oversight and compliance had improved since our previous inspection. Compliance with safety checks of equipment was being closely monitored via monthly ward manager reports. These were reviewed each month at the Maternity Operational Meeting. This was an improvement since our previous inspection.

Staff were required to check all equipment daily and replace any missing, expired, or damaged items immediately. Records demonstrated staff carried out daily safety checks of specialist equipment in triage and the antenatal ward but not always on the postnatal and labour ward.

We reviewed the record of daily checks for the previous 6 months for the adult resuscitaire on the labour ward and noted there were occasional gaps during 4 out of 6 months. The infant resuscitaire on postnatal had been checked at least once daily (97%) compliance and 91% for a second stretch target. All items on the emergency trolley were in date and available although the security seal was not correctly attached which meant emergency medications were not secure. We highlighted these concerns to the matron who dealt with the issues immediately.

The temperature gauge on the freezer used to store expressed breast milk (EBM) was not working. Staff were required to use a thermometer whilst waiting for the freezer to be replaced. However, it had not been checked since September 2024, and we saw EBM (dated October 2024) was stored in the freezer. We escalated our concerns to the matron who dealt with the issue immediately.

Leaders ensured electrical equipment had the required safety checks and monitored and maintained oversight of this. We saw 417 pieces of electrical equipment had safety checks completed in 2024 although 17 of those were non-compliant and there was no evidence to confirm what action had been completed. However, as part of the factual accuracy process leaders confirmed that the non-compliant equipment was not in use and the master copy now reflected this.

Overall compliance for health and safety awareness training was 90.2%. Sharps, such as needles, were disposed of correctly in line with national guidance. Staff disposed of clinical waste safely and arrangements for control of substances hazardous to health were adhered to. 

We received 8 feedback forms from women and birthing people who had used maternity services around the time of our assessment and although this was a very small number, 4 included concerns about short staffing.

Staff consistently told us that staffing was an issue on most shifts as there were not enough permanent staff. They also told us they were frequently moved to support 1-1 care in labour and maintain safe staffing. Leaders recognised that staff were working under increased pressure to provide safe care that met individual needs. They told us they did their best to ensure there were enough qualified, skilled and experienced staff although this was challenging due to their vacancy factor and unexpected events such as high acuity and staff sickness. Vacant shifts were often covered by bank or agency staff that were familiar with the service. Bank staff were generally allocated to manage the telephone-line in triage as this was not affected by continuity-of-care. Leaders had made improvements to midwifery and obstetric staffing for triage to support safe process, escalation and timely transfers. This included a dedicated midwife to manage the triage telephone-line. Staff told us this helped ensure women and birthing people had midwifery and obstetric reviews in line with their updated policy and process. Leaders had also provided protected obstetric and consultant cover for triage and although the protected cover was not 24 hours a day, it was a significant improvement since our last visit which was also reflected in audit results.

Midwifery staffing numbers were lower than planned. Managers looked at the acuity in each area and moved staff accordingly. We observed a safety huddle where staffing and acuity were discussed, and vacancies were planned for. Leaders told us they completed twice daily staffing reviews, and the use of their acuity tool ensured staffing concerns were escalated appropriately and mitigated for.

The consultant obstetrician covering labour ward was also required to cover gynaecology during situations where there was no gynaecology consultant. We saw this impacted on timely reviews of moderate to high-risk pregnant people. This included 4 delayed inductions of labour which needed an obstetric review and prioritisation, which did not occur until after 3:30pm. We did not see any evidence of mitigations and no escalation was triggered as an embedded part of business.

The maternity unit had also declared Operations Pressure Escalation Levels (OPEL) 4 which meant the system was under severe pressure. We expressed our concern to the clinical director and lead consultant for labour ward. We were advised that the system was frequently operating at OPEL 4 and that consultants who had protected time for administrative duties would help. There was also a new consultant starting in January 2025 and 2 locums had been recruited but the situation added considerable pressure to obstetric consultants.

Audit showed consultants provided the expected cover for labour ward. This included 90 hours per week, 2 daily rounds and a duty anaesthetist was available 24 hours-a-day. Results for the General Medical Council (GMC), annual survey for obstetrics and gynaecology showed significant improvement with no areas of major concern and 100% of medical staff had a recent appraisal.

We were informed most midwifery bank shifts were covered by part-time substantive staff who chose to work additional hours. In addition, the 27 midwives who had bank-only contracts, were all recent employees. This meant they were familiar with the service and could provide flexibility to cover vacancies, sickness, back fill for training and support during periods of escalation.

We noted an improvement in infection prevention and control during this visit and women and families told us the environment was clean

Staff told us they completed mandatory training on infection prevention and control annually and we saw most staff groups had completed this. Compliance for annual updates were 86.5% for midwives, 83.9% for maternity support workers and 83.3% for consultants.

Maternity service areas were clean and had suitable furnishings which were clean and well-maintained. Equipment had ‘I am clean stickers’ to show they had been cleaned that day. Privacy curtains were clean and labelled with their replacement date. We saw housekeepers going about their duties and they were familiar with the unit and cleaning polices. Staff were familiar with cleaning policies for the labour/birthing pools and cleaning records were up-to-date and demonstrated that all areas were cleaned regularly. Staff followed infection control principles including the use of personal protective equipment (PPE) which was stored in wall mounted displays. We saw staff were bare-below-the-elbow to support effective hand washing and we observed staff routinely used sanitation gel on entering and leaving ward areas. We saw visitors were prompted to decontaminate their hands on entering and leaving the department too. We observed effective hand washing techniques and leaders completed regular hand hygiene audits.

Matrons oversaw infection prevention and control across the maternity department. Oversight was maintained through monthly audits which showed compliance of 99%-100%. Audits highlighted occasional breaches to the hand hygiene policy, but leaders recorded how they actioned any breach with individuals, and we saw evidence that unsuitable mattresses were condemned and replaced.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. This was an improvement since our previous inspection.

Staff told us they checked the seals on the emergency trolleys daily and the full trolley was opened, and contents checked weekly. The trolley included medicines used for cardiac arrests, anaphylaxis and post-partum haemorrhaging.

Medicines were stored safely and securely in keypad secured cabinets that only authorised staff had access to the code for. Temperature monitoring was checked daily. Controlled drugs (CD) were stored safely and securely. A check of CD cabinets and record books showed that the stock levels were correct.

The service had scavenger units in areas where medical gases such as Entonox were used. They ensured staff were not exposed to Entonox vapours and exposure stayed within the workplace exposure limits protecting staff from harm.

The trust used a paper-based system to prescribe and administer medicines. Other information was recorded on electronic systems. We were told that medicines information was only kept on the active charts. We reviewed 9 prescription charts and saw they were up-to-date and fully completed.

Midwives, nursing staff and new doctors received medicine management and medicine safety training as part of their pre-registration training. Registered midwives and nurses had to pass the medicine assessments to be able to administer medicines unsupervised.

Staff were required to complete an incident form if a midwife or nurse were involved in a drug error. This raised an alert to their manager who oversaw their completion of the drug competency document to gain assurance that learning had been achieved.

Pharmacy support to the maternity unit was funded for 2 days per week. They routinely visited the unit on a Monday and Thursday to check and replenish stock levels and there were on-call arrangements outside of this.