Blackpool Victoria 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 assessed 8 quality statements. The service did not always have a positive learning safety culture where staff felt supported when dealing with incidents. Although the service had made progress to improve safe systems of care, they were not fully embedded. Staff did not always meet the trust target for safeguarding training or follow safeguarding policies. The service did not always work well with women to understand and manage risks or detect and control potential risks in the care environment. The service did not ensure all staff completed mandatory training or received effective support and supervision.

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

At our last assessment we rated this key question inadequate. At this assessment the rating improved to requires improvement.

This service scored 56 (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 did not always have a positive learning safety culture. Some staff we spoke with told us there was a lack of support when reporting and dealing with incidents. The service had a consultant rota in place for weekly governance reviews. However, some staff said that due to challenges with medical staffing, there was not always appropriate and timely obstetric input into incident reviews.

The trust provided data for the maternity service that showed an increase in incident reporting. The service had reported 1640 incidents between 2023 and 2024. This had increased to 1933 between 2024-2025.

Although staff understood what incidents were and knew how to report them on the electronic system, we saw inconsistent reporting. Staff told us that there had been a decline in incident reporting on the antenatal and postnatal ward D. We reviewed Learning from Patient Safety Events (LFPSE) incidents for the previous 12 months. LFPSE is a national NHS system for the recording and analysis of patient safety events that occur in healthcare. From December 2024 onwards, there were significantly fewer incidents reported related to delays in artificial rupture of membranes (ARM) compared to the previous months. During our assessment we observed a woman who was delayed over 24 hours for ARM and this had not been incident reported as per policy.

The trust provided data that confirmed a reduction in incident reporting of ARM and overall incidents on ward D. There had been 554 incidents overall reported between 2023-2024 and this reduced to 413 between 2024-2025. The trust clarified that the reduction in incidents for ARM was a key factor in the reduction of incidents on ward D. They told us this was due to a change in reporting requirements for ARM from December 2024 (3 months prior to our assessment) and was in line with Local Maternity and Neonatal System (LMNS) reporting requirements.

We reviewed the staff survey results for 2024 for the families and integrated community care (FICC) division. This included responses from the maternity service and showed that one of the best scoring responses was related to being encouraged to report incidents. However, only 44% of staff who completed the survey, felt confident that the organisation would address concerns about unsafe clinical practice. This was further evidenced as not all staff we spoke with said they felt confident that action would be taken in response to their concerns. Some staff told us about safety concerns they had escalated over the previous two years, and felt little or no action was taken.

The service provided evidence that senior leaders had conducted improvement workshops in summer/autumn of 2024 to listen to staff concerns. However, they did not provide evidence of an associated action plan to clearly show what actions had been taken following the workshops. The trust told us that the FICC Division had restructured its leadership model to enhance staff experience and that an action plan was due in May 2025 following the staff survey.

The trust had governance led daily MDT meetings to review incident categorisation, harm grading and learning response requirements. However, we found there was still inconsistent reporting and scoring of incident levels of harm. For example, we found serious obstetric emergencies reported and scored as low or minimal harm. A bladder injury was reported as no harm, and a uterine rupture reported as minimal harm. Although the service graded harm levels for both physical and psychological harm, it was not always clear how the psychological impact had been considered, when the harm scores for these incidents were determined.

We saw scores for levels of harm relating to post-partum haemorrhage (PPH) were inconsistent and the trust policy did not prompt staff to report PPH as an adverse incident on the trust's electronic incident reporting system.

This meant we were unclear how the trust was assured all incidents were reported correctly.

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

There were processes in place to review incidents daily and the service had weekly divisional meetings to discuss incidents in more detail, including what incidents were outstanding. However, we found incidents were not always reported consistently and closed in a timely way. For example, the service provided incident data that showed there were 89 incidents that were open between 60 and 492 days. This included four incidents of severe harm open between 60 and 107 days, and 35 moderate harm incidents, that were open between 69 and 349 days.

Leaders told us that the trust had investigated the incidents in line with good practice and Patient Safety Incident Response Framework (PSIRF) guidance. However, the PSIRF standards state that depending on discussions with those involved, learning responses are completed within one to three months and/or no longer than six months.

Learning from incidents that were rated moderate harm and above was shared with the board, through the maternity and neonatal report. The report dated March 2025 showed leaders worked with the Local Maternity and Neonatal System (LMNS) to provide a trajectory for the reduction of over 250 incidents and 27 rapid reviews.

The service took action to learn from incidents and to identify areas of improvement. Leaders had commissioned independent reviews for fetal medicine and category three caesarean sections. A category three caesarean section is classified as a non-urgent procedure where there’s no immediate life threatening risk. The independent reviews were in response to incidents with similar emerging themes related to the fetal medicine service and a notable increase in category three caesarean sections. The reviews were still in progress at the time of our assessment.

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

Senior leaders attended monthly safety panel meetings to discuss patient safety incidents in more detail. We observed minutes from meetings in January and February 2025 that identified areas of learning with associated actions.

The service had made progress to improve safe systems of care. However, not all systems were fully embedded.

Consultant-led ward rounds were not always conducted twice daily, in accordance with trust policy and best practice guidance. This meant women, and their babies were at risk of harm when there was no consultant to carry out the ward round. Reported incidents of when consultant led ward rounds had not occurred, resulted in delayed obstetric reviews, lack of daily risk assessments for delayed inductions of labour (IOL) and delayed discharges. We brought our concerns to the attention of senior leaders who told us that monthly audits to monitor consultant led ward rounds had commenced in January 2025. At the time of our assessment the audit data was not available. We were told it would be shared with CQC, safety champions and the maternity and women's directorate board when completed. In addition, consultant-led ward round sign-in sheets would be used to provide further assurance that ward rounds were being completed.

At our last inspection the service did not complete risk assessments for women and their babies when they were waiting for IOL. The service had since implemented consultant daily risk assessments and had updated their IOL policy in line with national guidance. The service had input and oversight from the Maternity Safety Support Programme (MSSP) for targeted support with IOL delays.

However, consultant risk assessments were not always completed in line with the IOL policy when women experienced delays in ARM to induce labour. We reviewed ARM audits from October 2024 to March 2025. Data showed that women who experienced a delay in ARM over 24 hours ranged from 6% to 50% for this time period. In March 2025, 21 women (27%) experienced a delay in ARM over 24 hours. Although this showed an improvement compared to October 2024 there was a decline in the number of daily risk assessments being completed. For example, in March 2025 only 48% of women had a daily risk assessment completed by a consultant or senior obstetrician. Eight women had not been risk assessed and this included three women who had delays of over 48 hours. The audits showed one action which was to work with the head of department to ensure daily risk assessments were completed. The audits did not show any subsequent actions taken to drive improvement or to investigate the reasons why the risk assessments were not being completed.

Since our last inspection the updated IOL policy included the reporting of IOL delays. We observed LFPSE incidents for the previous 12 months. We could see that staff had reported ARM delays or IOL delays that ranged from 24 to 106 hours. Some of the incidents reported that there was no consultant plan in place. We shared our concerns with senior leaders who told us that delays in ARMs were captured as a metric and monitored through the integrated performance report (IPR). We looked at recent IPR's that were shared with the board and they showed improvement in recent months. Leaders told us they planned to have additional IOL metrics by June 2025 to track delays and identify themes to aid improvement. This would be supported by LMNS partners.

The service had clear admission criteria, and the threshold for admission to the maternity unit was 16 weeks gestation. Women less than 16 weeks gestation who experienced issues or concerns, were referred to the early pregnancy assessment unit (EPAU) for review and management plan.

The trust had implemented a secure digital system for managing maternity records. Women and staff could access records via an online application that allowed easier access to information and enhanced continuity of care.

Feedback from external partners was that overall, women surveyed were positive about the application, and for many it was fully completed and functional, but also shared their frustrations and recommendations for improvements. They described `pockets of good practice' where the application was completed in full. They suggested clinically led review and regular training for all staff on the system was crucial for improvement. The trust clarified that since January 2025, training for the digital record system had been made mandatory.

However, the trust had not yet implemented the digital system for neonates. This meant it was more difficult to share neonatal care records with maternity and obstetrics teams and increased the risk of missing or unclear information.

We saw the trust had made improvements to the triage process and fully implemented a nationally recognised tool for clinical prioritisation. There was a dedicated triage lead with oversight of acuity. They would escalate flow or delay issues to the maternity bleep holder when needed. The unit had introduced a colour coded priority assessment tool to identify women admitted with reduced fetal movements to highlight urgency for review. There was also a clear separation between women who attended the triage unit and maternity day unit (MDU), with the two areas staffed separately. Staff told us that triage attendees were seen as a priority.

The triage unit had implemented a dedicated phone line, and a safety message explained to women what to do if their condition deteriorated while they waited. The ward clerk answered phone calls to take initial information, and this was shared with a trained triage midwife who gave advice. The service monitored waiting times and dropped-call rates. The trust provided data from June 2024 to December 2024 that showed the average waiting time was 15 seconds and the average dropped-call rate was 5.6%.

We observed three women in triage. They all received an initial assessment by a midwife within 15 minutes of arrival and were appropriately categorised according to clinical urgency. Staff completed associated audits to support ongoing improvement work and shared outcomes from audits with external partners including LMNS.

The service had improved processes to monitor staffing, capacity, patient flow and delays, which was supported with an escalation policy. Staff attended daily safety huddles with matrons, unit managers, safeguarding midwife and senior manager of the day. We observed one safety huddle and saw that staff communicated well and discussed staffing, acuity, capacity, IOL delays and consultant cover. Managers also attended meetings with system partners from LMNS Monday to Friday. These wider system meetings discussed staffing, capacity and mutual aid.

We saw improved safeguarding training compliance by midwives (including non-medical staff) against the trust target of 95%. Compliance with level 3 safeguarding adults and level 3 safeguarding children was 85.37% and 89.94% respectively. Level 2 adults was 87.95% and level 2 children was 94.29%. Compliance with preventing radicalisation training was 93.88%.

However, the trust still did not ensure all medical staff completed mandatory safeguarding training in accordance with trust target and policy. Although level 3 safeguarding adults was 100% for medical staff, the trust did not provide compliance rates for level 3 safeguarding children training. Level 2 safeguarding adults and level 2 safeguarding children was 30.77% and 62.5% respectively. Compliance with preventing radicalisation training was 81.25%.

Staff received baby abduction training. However, the service still did not participate in and undertake baby abduction drills in accordance with trust policy. The policy stipulates staff should complete baby abduction drills six monthly. Managers and staff we spoke with confirmed there had been no live drill in the last 12 months. However, during our onsite assessment a baby abduction drill was conducted. Following our assessment, the service provided information to show that this had been a live drill and that a further table top drill was planned for April or May 2025.

The trust had a procedure for reporting female genital mutilation (FGM) and clarified FGM was part of routine enquiry at antenatal booking appointments. If any type of FGM was disclosed, a referral was made to the team of complex social midwives. The service reported 29 cases from April 2024 to March 2025. However, incident data we saw showed staff had reported some instances of FGM that had no consultant oversight. This meant the service may not have full oversight of safeguarding and FGM concerns and reporting. We discussed our concerns with senior leaders who confirmed that national and local guidance had been followed. All women had been assessed by an appropriately trained registrar and had a named consultant and midwife. Leaders told us that current processes were under review and FGM incidents would now be triaged daily with divisional oversight.

The safeguarding team had weekly meetings and safeguarding midwives attended multidisciplinary meetings including child protection case reviews and child death reviews. They also attended pre-birth meetings to discuss the challenges and issues experienced by vulnerable women and their families.

The service had comprehensive and in date adult and children safeguarding policies that staff could follow for guidance. Staff we spoke with knew how to make a safeguarding referral and who to inform if they had concerns. Staff explained safeguarding procedures, how to make referrals and how to access advice. They told us that the safeguarding team was supportive and were on the unit daily to offer assistance when needed. Staff told us that they had clinical supervision but would benefit from more psychological support to help with difficult situations they were exposed to.

We saw safeguarding informational posters displayed. For example, modern slavery and sexual abuse information.

Staff we spoke with gave examples of how to protect woman from abuse, harassment and discrimination, including those with protected characteristics under the Equality Act. Staff understood the importance of supporting equality and diversity and ensuring care and treatment was provided in accordance with the Act. Staff gave examples of how they had considered the needs of women with protected characteristics.

Staff we spoke with told us that domestic violence and sexual abuse were routinely discussed with women attending clinics. We saw a system in place whereby vulnerable women could alert staff by leaving a red sticker on their specimen pot. Staff told us there was an early help scheme for women who were experiencing domestic violence.

The electronic patient record system flagged specific needs, for example a yellow flag indicated a safeguarding need. Staff told us that community partnership information sharing (CPI) was also checked and used to identify young women who have safeguarding requirements.

Staff used newborn early warning trigger & track (NEWTT) and modified early obstetric warning score (MEOWS) tools to detect and escalate deterioration quickly. We reviewed three women's records and saw that these were fully completed and scored appropriately. However, the trust confirmed they did not audit compliance. This meant we were unclear how the trust was assured managers had sufficient oversight of compliance and escalation.

Compliance with documentation of cardiotocography (CTG) was monitored though peer review and periodic informal `spot audits' and results were variable. Data we saw for 10-16 February 2025 indicated 80% compliance for completing `fresh eyes' at each hourly assessment. We looked at three women's records and found gaps in documentation being signed at the end of the CTG and one record showed gaps in staff completing the `fresh eyes' approach. The trust told us CTG reviews would be included on the fetal monitoring training for 2025, and the delivery suite manager and maternity matron would maintain oversight of spot audits until compliance increased. In addition the trust was part of a working group with LMNS to support a system wide response.

The service completed an annual audit of antenatal care and had an associated action plan to address any non-compliance. However, it was difficult to assess any improvement based on the annual audit cycle and low sample size of 30 records over one year. In addition, the service confirmed it did not conduct audits of pain management. This meant we were unclear how the service was assured assessment of women's pain levels were always completed.

There was no formal process and policy for high risk women who chose to give birth outside of guidance. This meant that there was no clear process to support women who were likely to disengage with the service if their birth wishes were not aligned to national guidance. Leaders explained although there was no formal policy, if made aware of a woman's intention to freebirth, there was a letter sent to the woman outlining antenatal care, the role of the midwife and the legal obligation of notifying the birth of the baby. However, we were unclear how the service would follow up with women who did not comply with the legal obligation to notify maternity following the birth of their baby.

We asked for audit data and associated action plans of questioning around domestic violence, post-natal mental health and other vulnerabilities. The trust confirmed they collected this information at the initial booking appointment but did not audit staff compliance or analyse the data collected.

The service extended visiting times on ward D, in December 2024 to allow `open visiting'. For example, partners could now stay 24 hours and sleep over with their own reclining chair and shower facilities. Children and other family members could also visit from 8am until 11pm each day.

However, there was no risk or impact assessment completed prior to implementation and staff we spoke with shared concerns regarding lack of clear policy and guidelines to support them. They gave examples of incidents they had reported, including difficulties delivering care and disrupted medicines rounds, due to large numbers of visitors present on the ward during day and nighttime. Midwives also reported being distracted from duties due to having to let visitors in and out of the ward.

In addition, there were no baby abduction drills completed for over 12 months, although the trust policy stated these were to be completed 6 monthly. This meant we were unclear how the trust was assured babies were always kept safe and any possible risk and impact from the increase in visiting hours was identified or risk assessed.

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

Women could access support from a perinatal mental health specialist team. The service had a specialist perinatal mental health midwife who offered mental health clinics including joint clinics with a consultant psychiatrist. Staff told us that adaptations were put in place in response to trauma in order to meet their needs.

Staff told us that it was difficult to fully support mental health birth plans due to resource and capacity of perinatal mental health midwives, social workers and psychologists.

We found the service still had gaps in the process of monitoring and servicing equipment. For example, we saw bladder scanning equipment on MDU due for service in 2022 and recorded on the maintenance register as ‘lost’ after two consecutive attempts to locate and service it. This meant there was a risk staff may use equipment which was not fit for purpose or unsafe. We brought this to the attention of staff at the time and it was removed immediately.

In addition, we found 29 assets (equipment) from 2021 to March 2025, that were marked as ‘lost’ across the inpatient and community service. We shared our concerns with leaders and staff took action to review equipment across the maternity units and removed any out-of-date items. Managers worked with estate colleagues to confirm that any assets marked as lost were not located in patient areas. Leaders told us that overall compliance for the trust’s medical devices in February 2025 was 94%.

Most checks of emergency equipment were completed in accordance with policy. However, daily emergency equipment check records on ward D were incomplete. For example, there were five gaps in February and six in March 2025. During our assessment we found items missing from the emergency resuscitation trolley, which meant checks previously recorded as complete may not have been sufficiently thorough. This meant there was a risk staff may use expired items or items might be missing in an emergency situation. We brought this to the attention of a midwife at the time and staff immediately replaced the missing items.

We observed gaps in stock rotation. In the triage unit we found syringes and saline past their use by date. These were given to staff and removed. Managers took action to check all remaining stock, and leaders told us that they were reviewing roles and responsibilities to include stock control.

There were now shared facilities between triage and MDU. We observed that following scans, women were sent to the MDU for follow up rather than to clinic. Staff we spoke with told us MDU was too small, with two beds and one chair, and unsuitable screening with curtains. This meant women’s privacy and dignity may be compromised and conversations could be heard. Women who needed vaginal examinations had to wait for a triage room to be vacated, which staff felt, impacted on triage access and flow. However, trust data suggested that triage wait times were in line with national targets.

On ward D, there was now a secure fridge where breast milk could be stored. We observed the expressed breast milk fridge was locked and bottles were clearly labelled with expressed dates and women’s names. However, we found three bottles were not removed after the expiry date. We made staff aware at the time and the bottles were removed. Leaders told us that the housekeeper checklist had now been amended to include daily checks of breastmilk and would be monitored by spot audits.

We saw risk assessments for environmental ligature points were completed appropriately in all areas.

Security of the unit was in line with national guidance; the unit was fully secure with a monitored entry and exit system.

There were enough resuscitaires and CTG machines with Dawes Redman capability. There was centralised CTG monitoring for antenatal women.

The trust provided comprehensive mandatory and specialist maternity training. However, managers still did not always make sure all staff completed it. Although we saw improved midwifery compliance with mandatory training, medical staff were only compliant with the trust 95% target for 2 of 13 mandatory modules, including safeguarding.

Staff completed study days for additional mandatory training relevant to their role including maternity update days, maternity obstetric drills and fetal wellbeing days. The training was attended by obstetricians, anaesthetists, midwives, and maternity support workers. The maternity obstetric drills study day covered a wide range of obstetric emergencies such as post-partum haemorrhage, impacted fetal head, breech births and third and fourth degree tears. We now saw improved compliance rates. Data from March 2025 showed compliance was 99% across all staff groups which met the trust target.

The service now had 12 trained professional midwifery advocates (PMA's) to support professional development and supervisions. The service also had a preceptorship and retention midwife, two practice development midwives and a multi professional educational team. Comprehensive educational sessions were planned in a structured schedule and staff we spoke with confirmed training was never cancelled.

We observed that midwifery staff were recruited in accordance with trust policy and all personnel documents were stored electronically in individual files. Upon appointment, all midwifery staff received a formal trust and departmental induction. New starters and band 5 midwives also attended PMA meetings, where they were supported through incident investigations when required.

The regional preceptorship survey identified the trust as having received consistent positive feedback from new midwives. Newly qualified midwives we spoke with told us they felt the training and preceptorship support, they received was very good. Leaders clarified that the supernumerary hours offered was above the national recommendation.

However, staff told us they did not always receive the supernumerary time before they started clinical work. Staff told us that newly qualified midwives had worked many supernumerary shifts caring for women and babies alone without another midwife to work alongside, and this concurred with incident reports we saw. For example, in November 2024 ward D was reported to have a very high acuity with two midwives to care for 22 women and their babies. One midwife was newly qualified. In March 2025 it was reported that there were no core midwives on the delivery suite and two supernumerary midwives were unable to be supported properly. Following our assessment, the trust provided data for staffing levels of intrapartum staff (core delivery suite staff). Data showed that in March 2025, a core staff member was present for 81% of shifts. Leaders said that shifts without a core staff member has at least one senior band 6 midwife present.

Midwifery staffing

The service had local and regional policies for the escalation of staffing and capacity. Managers used Birthrate Plus which is a nationally recognised tool for calculating safe staffing levels. There were twice daily operational huddles to review capacity and staffing in addition to daily site management meetings that took place four times a day.

Since our last assessment we saw improved numbers of midwives and there were now 15.7 whole time equivalent (WTE) specialist midwives in post. This included a perinatal mental health midwife and a complex social care midwife. However, board papers from March 2025 indicated maternity was still not fully compliant with the Birthrate Plus recommendations. There was a shortfall in the midwifery establishment of 8 WTE and skill mix was not always optimal. A business case had been submitted to increase the midwifery establishment. An action plan was in place and recruitment and preceptorship midwives were appointed to support with maintaining retention of staff.

We observed workforce data for the FICC division that showed the sickness rate for nursing and midwifery staff was 8% in December 2024 and January 2025. Data showed a gradual increase from May 2024 when the sickness rate was 6% and had matched the planned rate. The turnover rate for nursing and midwifery staff in January 2025 was 5.6%, this was lower than the planned rate of 11% and had improved from 7% in October 2024.

Staff we spoke with told us that specialist midwives were often used to fill gaps in staffing. This meant they had less time to focus on their specialist role and duties. In addition, the service utilised community midwives to help improve staffing numbers. Staff told us that the week prior to our assessment, community midwives had been asked to provide support to cover staff absence. This meant there was less staff to manage the community workload. However, trust data showed that in the previous 12 months there had been no home births cancelled.

The planned staffing for the 22-bed antenatal and postnatal ward (ward D) was three midwives and two maternity support workers (MSW) for day and night shifts. During our assessment we saw the actual number of staff matched the planned numbers.

However, staff we spoke with told us that ward D was mainly staffed by two midwives and one MSW. They also described occasions when ward D had been extremely short staffed because midwives had been moved to support the delivery suite. Following our assessment, the trust provided rota examples from January to March 2025. Data showed that ward D was staffed with 3 qualified midwives 95% of the time. The rotas showed the planned staffing levels. The trust did not provide actual versus planned staffing levels to show that the planned staffing levels were actually achieved.

This concurred with LFPSE incident data we saw for the previous 12 months, which showed that staff had reported incidents relating to suboptimal staffing across various units and wards. For example, delayed IOL due to staffing capacity issues on the delivery suite. This was unsafe because this increased the risk of complications during birth and associated harm to women and their babies. However, between February 2024 and March 2025 the service consistently achieved 100% compliance for providing one-to-one care during established labour.

We found there were not always sufficient staff to act as scrub practitioners in maternity theatres. Staff we spoke with told us this, and incidents we saw showed there was occasional reliance on bank staff from general theatre and midwives from the ward to provide scrub staff in maternity theatres. We brought our concerns to the attention of senior leaders who told us that the maternity service had trained midwives and scrub practitioners to ensure cover over a 24 hour period, seven days a week. This included one permanent theatre co-ordinator scrub who worked three days a week and two regular bank and agency theatre practitioners who covered night shifts seven days a week. Midwives trained in the scrub role would cover on occasions when there was no designated scrub cover. Leaders told us this occurrence was low and provided data from April 2024 to April 2025 that showed midwives had supported the scrub role in 2.9% of theatre cases. The service had submitted a business case to appoint two substantive scrub practitioners by September 2025 and were reviewing the workforce requirements for theatre activity.

We requested maternity National Institute for Health and Care Excellence (NICE) red flag events data. A maternity red flag event is a warning sign that something may be wrong with midwifery staffing, such as delays to triage, delays to inductions of labour and delays in administering pain relief.

Trust red flag data provided for the period 1st September 2024 to 28 February 2025, showed 113 red flags raised. 103 of these were instances when the labour ward co-ordinator was not supernumerary, because they were required to support with care giving. There were another four occasions where the labour ward coordinator provided one-to-one care in labour and was unable to maintain supernumerary status. Delay in providing pain relief was 0%, delay between presenting and triage was 0% and delayed induction of labour was 0%.

However, we found examples of delays in pain relief, triage and induction of labour recorded in the LFPSE system for the same period, which were not reflected in red flag data. This meant we were unclear how the trust was assured managers had clear oversight of all red flags and understood the potential and actual risks of suboptimal midwifery staffing on women and their babies.

Medical staffing

Consultants covered both obstetrics and gynaecology. Staff we spoke with told us that there was pressure to cover the consultant rota due to current vacancies. During our assessment we observed gaps in the consultant rota for March 2025. This was unsafe because women were not always assessed timely and safety incidents reported by the trust showed delays in high-risk women receiving elective caesarean sections due to gaps in consultant cover. We brought our concerns to the attention of senior leaders who provided assurance around rota compliance and medical cover across all areas. They acknowledged there had been instances where elective caesarean section lists did not have dedicated consultant cover due to vacancies or annual leave. Leaders recognised there was still insufficient capacity for elective caesarean sections and had developed a business case to request additional funding and resources for support.

Leaders told us that the planned establishment for consultants was 12.80 WTE's. There were ten substantive consultants and three vacant posts. One of the vacant posts was expected to be filled in August 2025 and the two other vacancies were currently covered by long-term locum consultants with projected recruitment September 2025. They told us that ten consultants (including the locums) participated in the on-call rota.

Leaders told us that they were reviewing consultant capacity and job plans. This would be incorporated into the trust wide obstetrics and gynaecology workforce service review. The service had implemented a new rota system from April 2025 to improve coordination and oversight of consultant and medical staffing. The new rota system would also be used to plan for elective caesarean sections with enhanced oversight by the head of department and rota coordinator. Leaders told us this would help identify and escalate potential gaps in a more timely manner. The service planned to update local standard operating procedures related to elective caesarean sections by July 2025.

Workforce data for the FICC division showed that the sickness rate for medical staff was 1.5% which was lower than the 6% planned rate. This had gradually reduced from 8% in September 2024. The turnover rate for medical staff was 18.45%.

Staff we spoke with shared concerns regarding the number of ultrasound scans that were sent to the MDU to be reviewed by a doctor. They told us that doctors were not always available, and this impacted on pre-booked appointments and waiting times. Staff told us that there were occasions when midwives had reviewed ultrasound scans when a doctor was not available. We observed the ultrasound policy provided by the trust but it did not describe which staff roles were responsible for reviewing ultrasound scans. This meant that it was unclear whether midwives were working beyond the scope of their professional practice.

Following our assessment, the trust clarified that midwives reviewing scans was not in line with trust guidance. They told us that regional guidance was in the process of being ratified and all midwifery staff have been reminded to remain within their scope of practice.

We shared our concerns about medical staffing with senior leaders. They told us that they had completed a comprehensive review to realign workforce deployment to the needs of the service. They said that since April 2025, the adjustments had enabled consistent senior cover during core hours for triage and MDU. Leaders also told us that from August 2025 there would be separate rotas for triage and MDU to improve clinical demand at peak arrival times. This would include one registrar available from 8am to 4pm and a second registrar from 12 noon to 8 pm.

Consultant capacity and job plans were being reviewed in May 2025. This would be incorporated into the trust wide obstetrics and gynaecology workforce service review and expected to be completed September 2025.

At the time of our assessment, six locum doctors were employed. However, there was no formalised induction process for locum doctors and the trust confirmed the policy for managing locum medical staff induction, was in draft, not referenced or version controlled and not ratified. This meant we were unclear how the trust was assured locum medical staff received a formalised induction, were supported to practice in accordance with trust policy and fully trained regarding trust emergency procedures.

We requested the trust policy for staffing escalation and mitigation to include out of hours consultant and anaesthetic cover provision. However, the policy we received did not include medical staffing and the trust confirmed there was no written procedure for management of medical staffing in place. This was due for completion in April 2025.

In addition, the staffing escalation policy we saw alluded to red flag triggers to escalate clinical concerns and report incidents when there was a risk to quality and patient safety (due to staffing issues). However, these were nursing red flags not maternity-specific red flags, such as delays to induction of labour and delayed epidurals. This meant the staffing escalation policy was not specific and relevant to the services provided and there was no clear guidance for maternity staff to follow, to escalate maternity red flag events caused by suboptimal midwifery and medical staffing.

We requested compliance rates against the trust target for performance appraisals for all maternity staff groups. However, data provided from February 2025 did not state the trust target and included staff groups across all women's health services, rather than maternity specific staff compliance.

For example, women's heath total compliance was 74.52%. Midwifery 79.55% and women's health medical staff was 84.62%. In addition, the staff survey 2024 data indicated for the women's health division, 57% of staff said they had received an appraisal in the last 12 months compared to 80% of staff across the organisation.

Some staff we spoke with told us the appraisal process felt like 'a tick box exercise' to be filled out in advance rather than an opportunity to discuss face to face where they saw their development needs to be and how they would achieve them.

The trust clarified that recovery of performance in terms of appraisals was anticipated by end of Q1 of 2025/26 (June 2025). However, non-compliance with completion of appraisals and actions to address this was not evident on the risk register. This meant we were still unclear how managers had full oversight of maternity staff performance.

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

Each area of the maternity unit had a dedicated cleaner. Cleaning services were contracted by the trust. Cleaning staff did not use checklists in clinical areas to evidence that areas were cleaned but followed a cleaning charter. Each clinical area of the unit had a bespoke list of cleaning tasks, cleaning frequencies and responsibilities. Check lists were used only in public areas of the trust. Staff cleaned throughout the day and if additional cleaning was required overnight then a response team attended the unit.

Weekly audits were undertaken by cleaning supervisors and feedback to staff was given.

The trust told us there was consistent achievement of 5-star cleanliness ratings across both delivery suite and ward D and that assurances were gained through the divisional quality and safety committee. We looked at cleaning audit data from December 2024 to February 2025 which showed MDU, delivery suite and ward D met the acceptable thresholds with consistent scores ranging from 93% to 100%.

Clinical equipment was cleaned by the midwifery staff. Staff cleaned equipment after use. ‘I am clean’ stickers were used to show that a piece of equipment was clean and ready to use.

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

Staff accessed hospital infection prevention and control policies on the intranet. Staff followed infection control principles including the use of personal protective equipment (PPE). We observed staff complied with ‘bare arms below the elbows’ policy, in accordance with NICE guidance. We observed staff washed their hands and used hand sanitising gel between interactions. Hand hygiene audit total compliance ranged from 87.5% to 99.3%.

The service still did not have an effective system in place for curtain changes. We observed disposable curtains in triage that had not been changed in accordance with trust policy. This was escalated to staff and they were immediately changed. Leaders told us that they had since made changes to the processes and this would be monitored as part of the matron’s check.

There was a process for obtaining routine and emergency medicines 24 hours a day, seven days a week. The service was supported by on call pharmacy services out of hours. However, the service did not have a dedicated pharmacist. Staff we spoke with told us this impacted on provision of discharge medicines and discharges were not always timely.

Safe storage of medicines had now improved. For example, October to December 2024, audit data showed ward D 88.4% and delivery suite 91.7% compliant. Controlled drugs (CD) management audits for October 2024 and January 2025 showed that ward D compliance was 98%. This met the trust target of 90%. The triage unit compliance had reduced from 94.4% in October 2024 to 79.4% in January 2025. The delivery unit and maternity theatre did not meet the trust target for the same time period. Compliance ranged from 85.3% to 89.2% and we saw action plans in place to drive improvement.

During our assessment we found controlled drugs locked in the CD cupboard but the balance did not reflect the stock. We brought this to the attention of managers at the time and they were entered correctly.

Medicines fridge temperatures and ambient room temperature checks were completed well.

Medicines management training was provided for midwives, nurses and allied health professionals. Medical staff received prescribing training on induction. Trust target compliance rate was 90%. Midwives compliance with e-learning was 86.78% and practical training 95.87%. Overall maternity compliance with medicines management training exceeded the trust target for December 2024, January and February 2025.

Trained midwife prescribers used patient group directions (PGDs) for maternal immunisations and those we saw were all in date and appropriately authorised.

Prescription charts we saw were all completed in accordance with policy.