St Richard's 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 that women were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination.

At our last assessment we rated this key question requires improvement. At this assessment, the rating of safe had not changed and was requires improvement.

Following the inspection, we found there was a breach of Regulation 12: Safe care and treatment.

The layout of the maternity assessment unit and demand on the service meant women were at times required to wait in an external area, where staff did not always have direct visual oversight. While mitigation was in place, including CCTV and access to an emergency call system, this did not replace direct observation and posed a risk to safe monitoring.

Data provided by the trust showed over a 6-month period, 84% of women received a midwifery review within 15 minutes of arrival. This was slightly below the trust target of 90%.

However, staff knew what incidents to report and raised concerns and reported incidents and near misses in line with the trust policy. The patient safety team had oversight of the grading and reviewing of incidents with a clear system to investigate incidents and to identify learning.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We scored the service as 2. The service did not always have a proactive and positive culture of safety.

The service combined the number of open low or no harm incidents with the sister location Worthing hospital. This meant there was no clear indication as to whether there were issues with closing incidents at a particular site.

At the time of the inspection there were 123 open low and no harm incidents reported, with 48 of those incidents being more than 20 days old. Although incidents were graded as low or no harm, delays in review and closure increased the risk that indicators of poor care were not identified. This limited the service’s ability to recognise themes, trends, or areas of non‑compliance requiring improvement.

Staff knew what incidents to report and raised concerns, reported incidents and near misses in line with the trust policy. The service used national risk tools, Patient Safety Incident Response Framework (PSIRF) and a Perinatal Quality, Safety Risk Framework to review and monitor risk.

The patient safety team had oversight of the grading and reviewing of incidents with a clear system to investigate incidents and to identify learning, using the PSIRF model. PSIRF was embedded within maternity and learning from incidents was shared with maternity teams, through email alerts and messages during daily handover.

The perinatal mortality review tool (PMRT) is a tool to support objective and standardised local reviews of care if a baby dies. The service had 3 perinatal mortality review tool (PMRT) cases within the last 6 months.

Quarterly PMRT reports were submitted to the trust board and cases submitted to Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries (MBBRACE) within 7 days of a baby’s death and duty of candour was given to all families.

MBBRACE is a national program focusing on improving maternal and infant health. Questions and feedback received from women and their families were presented to the PMRT review panel as part of the review and the trust responded to questions raised. PMRT reports were reviewed by a multidisciplinary team.

The service engaged with the Maternity and Newborn Safety Investigations (MNSI) programme. MNSI is a national strategy to improve maternity services. The service had 4 MNSI reported cases over the last year.

A multidisciplinary (MDT) or obstetric review of incidents took place weekly. In addition to these reviews the patient safety midwives met with ward leads weekly to discuss incidents which did not require an MDT or obstetric review. Community incident reviews were twice weekly and was community focused only.

Monthly situation, background, assessment and recommendation (SBAR) learning from incidents was shared with all staff and displayed on safety and staff notice boards throughout the unit.

Maternity staff had access to a team’s channel which contained incident reviews, improvement plans and tools could be accessed.

Anonymised incidents and complaints presented within the maternity governance meetings and local maternity and neonatal system (LMNS) quality and safety meetings were used during trust maternity mandatory training.

We scored the service as 2. The service did not always work well with people to establish and maintain safe systems of care. They did not always manage or monitor people’s safety.

Systems and processes within maternity triage were not embedded to ensure women were safe. The service was not meeting the target of 90% for women to receive an initial review by the midwife within the maternity assessment unit and were not always prioritised appropriately.

The maternity assessment unit (MAU) was the service’s maternity triage area. The MAU is an urgent 24-hour service to assess and treat pregnant women where there were urgent concerns. Midwives used a nationally recognised tool to rate risks consistently.

Monthly audits were completed to determine how long women waited for initial assessment and if they required a medical review.

At the time of our assessment the maternity assessment unit (MAU) was staffed with 1 band 6 midwife and 1 maternity support worker. The unit was small and confined, and women were required to wait outside the MAU. As a result, staff did not always have a direct line of sight, which meant continuous observation to identify deterioration was not consistently maintained.

Although the service had fewer than 3,000 births per year and did not routinely require two midwives in triage, we did identify concerns around staffing levels during times of increased activity. We shared our concerns regarding MAU staffing and following the assessment the service introduced a second midwife during peak times, to support the MAU when more women attended.

The maternity assessment unit standard operating procedure set the target for women to be seen and assessed within in the MAU within 15 minutes of arrival. Data between March 2025 to August 2025 showed the service were close to meeting the trust target of seeing and assessing women within 15 minutes. Target figures for those months were between 82% to 88%.

At the time of assessment, the service did not audit or record the times women waited for a medical review within MAU. A review of women’s records within MAU identified that 50% of delays was due to women waiting for a medical review. Following concerns raised about limited oversight of medical reviews for women, the service introduced a resident doctor to be rostered on each shift within the MAU, where required.

However, there was no further data received to ascertain whether the times women had received a medical review had improved. The risks of not having a timely medical review meant delayed decision making, further complications to the woman and their unborn baby.

Although there were delays in reviewing women due to staffing within MAU, we did find staff were trained to respond to risk and were able to identify and act when women were at risk of deterioration. Staff completed risk assessments and took action to remove or minimise risks, and documentation was completed appropriately.

The CQC coordinates a national survey annually to look at the experiences of pregnant women and new mothers who used NHS maternity services. This survey looked at the experiences of pregnant women and new mothers who used NHS maternity services in 2025. It is CQC coordinated with other stakeholders, but it is reported by us at CQC. We reviewed the latest findings of the maternity survey 2025. We saw that when women were asked “Thinking about the last time you contacted the telephone triage line, did you feel that you got the advice you needed?”, the service scored 8.9, which was above the national average of 8.3 when compared to all other trusts in England. For the question “Thinking about the last time, you attended triage face-to-face, did the midwife or doctor you spoke to listen to you?”, the service score 9.1, which was above the national average of 8.7.

The service provided a centralised maternity telephone triage which received calls for all four of the trust maternity locations. The local maternity and neonatal systems (LMNS) insight visit in August 2025 recognised improvements in the centralised telephone triage service. There were no further maternity and newborn safety investigations linked to telephone triage, and there was a 40% reduction in born before arrival (BBA) cases. This meant there was improvement to women accessing advice and reducing avoidable risks for women.

Staffing red flags in maternity care can identify a lack of adequate maternity staffing, which can lead to unsafe care for women and their babies. Red flags may also occur due to staffing shortages, which can affect the ability to provide safe care.

Red flag data was reviewed and we saw in June 2025 there were 21 incidences of the labour ward coordinator unable to maintain supernumerary status of not providing one to one care. In July 2025 and August 2025 there were 6 incidences reported each month of incidences where the service was unable to fill vacant shifts and there was unexpected staff absence.

The maternity dashboard was reviewed and from March 2025 to August 2025 the labour ward coordinator was 100% supernumerary in the delivery suite. This meant the labour ward co-ordinator was able to have full oversight of the maternity unit and were able to allocate resources to effectively meet the needs of women and their baby.

Staff attended two cross-site daily status (sitrep) meetings each morning where they discussed the current and emerging situation at both such as staffing levels and capacity at St Richard’s Hospital and Worthing Hospital. The director of midwifery (DOM) or head of midwifery (HOM) chaired the meetings. The agenda included staffing, bed capacity and learning from recent incidents.

The second meeting covered all four hospital sites and used information from the first meeting to identify any areas of concern and address immediate concerns across the whole trust.

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 assessment we attended handover meetings and safety huddles. We found them well attended and used to fully discuss women and any emerging concerns.

Transitional care for babies provided extra support beyond the usual postnatal care but were well enough to be cared for at the bedside with their mother. Care for transitional care babies were provided by the midwifery and neonatal teams. All babies were reviewed daily by the neonatal team.

Staff completed newborn risk assessments using recognised tools such as the Newborn Early Warning Trigger and Track (NEWTT) tool to record observations and feeding. All babies who needed special care or transitional care were discussed at an avoiding term admission into neonatal units (ATAIN) meeting. The ATAIN meeting focused on reducing unnecessary admissions of full-term babies to neonatal units by identifying and addressing potential issues.

We scored the service as 2. The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

During the assessments of the four maternity service locations, it was identified that the trust did not follow the Intercollegiate Document for Safeguarding Children and Young People 2025 or the Royal College of Nursing adult safeguarding: roles and competencies for health care staff (2024/2025) guidance sets out that health care staff engaged in assessing, planning and delivering care should be trained in adult level 3 safeguarding.

Data showed at the time of our assessment there were no midwifery staff trained to this level. However, since the inspection the trust had introduced a rolling programme of level 3 adult safeguarding training to midwives and obstetric teams.

Maternity and medical staff were 95% compliant in safeguarding adult level 2 training. Maternity staff met the trust compliance for level 3 safeguarding children’s training with 95%. Medical staff had 87.7% compliance, which did not quite meet the compliance of 90%.

Staff told us they had access to the safeguarding lead midwife. The safeguarding midwife was located within the unit and offered support or guidance to staff when needed.

The safeguarding team had clear escalation pathways and reported to the board via the hospitals safeguarding lead. Staff completed assessments for women to identify and support those at risk of self-harm and suicide. During a review of women’s maternity records, we saw staff asked safeguarding questions at each antenatal contact if safe to do so.

Staff placed a flag on women’s records if safeguarding issues were identified. This included staff in the emergency department. This allowed staff to easily identify women or babies at risk.

Women who did not attend hospital appointments were flagged to the community team for follow up. Women who regularly did not attend appointments were reviewed at risk meetings to support timely contact. Where concerns or continued non‑engagement were identified, safeguarding referrals were made to relevant external agencies.

The trust had appropriate safeguarding policies that aligned with national guidance and a designated safeguarding midwife. Midwifery and obstetric staff 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.

The service supported vulnerable women throughout their pregnancy and birthing journey with a ‘one stop clinic’. The clinic saw women with substance misuse and were provided support from the obstetric, safeguarding, smokefree pregnancy and paediatric teams.

There was a pathway to support perinatal women during a psychiatric emergency. Postpartum psychosis is a severe mental illness which can start suddenly during the final trimester of pregnancy or in the days or weeks after having a baby.

Staff followed safe procedures for partners and families visiting the wards. The service strictly controlled access to all areas. Staff undertook baby abduction drills, so they knew what to do in the event of an attempted baby abduction. Staff told us there had been a baby abduction drill within the last 12 months.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with women to understand and manage risks. Staff did not always provide care to meet women’s needs that was safe, supportive, and enabled women to do the things that mattered to them.

The trust reviewed Cardiotocography (CTG) monitoring and intermittent auscultation through completing fresh eyes to gain reassurance of staff competence and completion. Cardiotocograph (CTG) and intermittent auscultation was a method of fetal monitoring during labour that involves listening to the fetal heart with a doppler ultrasound.

The electronic record system showed the compliance rate for completing ‘fresh eyes’ monitoring was below the trust compliance, with only 12.7% of fresh eyes completed. The service completed a paper-based review of ‘fresh eyes’ to identify potential issues with pulling information through within the electronic data system. The paper-based review identified the service continued to not meet the trust target with only 40% compliance.

‘Fresh eyes’ provide an independent and objective assessment, which is essential for improving the safety of women and reducing the risk of errors in the interpretation of fetal wellbeing during labour, and supporting safe and timely clinical decision‑making.

The service did not provide information relating to why ‘fresh eyes’ compliance did not meet the trust target. However, despite the service not completing hourly ‘fresh eyes’ reviews, the service noted escalation of care was always appropriate.

Hypoxic-ischaemic encephalopathy (HIE) is a term for a brain injury that happens before, during, or shortly after birth when oxygen or blood flow to the brain is reduced or stopped. The maternity dashboard showed the service was slightly higher than the national average of 4.25 per 1000 births for HIE rates, with no cases in June 2025, 5.13 for July 2025 and 5.05 for August 2025. Following the reporting process the service reported the 12-month rolling rate for suspected HIE cases for July 2025 was reported to be 1.4/1000 births. However, the service did not provide the updated confirmed number of cases.

Women attending the service for an induction of labour (IOL) were given an initial date for admission to start the induction process. Women were advised that this date may change based on acuity and the prioritisation according to clinical risk.

Information received from staff showed there were regular delays in women receiving the IOL. We requested the number of IOL delays and time of waits between May 2025 to October 2025 for the hospital. Although the service reported that 24% of women attending St Richard’s hospital had an IOL, they did not collect data regarding the waiting times. Collecting wait times for IOL helps services identify delays that may increase risks to women and babies. It supports effective capacity planning, oversight, and assurance that care is provided in a timely and safe way in line with clinical guidance.

The service had recently updated their clinical guidelines and formed an IOL discussion group to listen to concerns and to explain emerging plans. However, without collecting waiting time data, the service could not clearly identify reasons, themes or trends for delays in induction of labour to improve women’s experiences and fully alleviate risk.

The risk assessment (RAG) rating at birth tool was embedded within the electronic patient records and all babies were risk assessed within the first hour of birth. This identified whether babies were low or high risk at birth. This supported the identification of early onset of sepsis and babies who were higher risk of clinical deterioration.

Documentation audits were not completed as a standalone audit, instead the service completed a maternity incident review process which looked at the maternity journey of the woman. Any failures identified within the documentation practice triggered a shared learning review. The service recognised that this was not a usual documentation audit, noting specific triggers. However, they felt it provided assurance about practice within maternity as well as identifying trends.

Not completing stand‑alone documentation audits reduces oversight of record‑keeping standards and increases the risk that poor practice is not identified. This can affect patient safety, continuity of care, and the trust’s ability to provide assurance of care quality.

The service provided staff with a fluid balance 3-day workshop for fluid balance recognition as part of scenario training for multidisciplinary skills. This was following a decline in staff completing urine output and fluid balance documentation. Staff were reported to be 98% compliant in fluid balance training. However, the service did not report if there had been an improvement in documentation following the training.

The service had developed a hyponatraemia in labour guideline, and a hyponatraemia prevention communication was circulated to both women and staff. Hyponatraemia can occur during labour, particularly where labour is prolonged, oxytocin (a hormone used to stimulate uterine contractions to facilitate labour and delivery) is used, or fluid intake is not appropriately managed. If hyponatraemia is not effectively managed, it may increase risks to women and babies. Prompt identification and escalation help support safe care.

The service held consultant-led labour ward rounds twice daily, 7 days per week. Consultants also attended a weekly multidisciplinary meeting (MDT).

We scored the service as 2. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The service provided a full range of maternity services. Maternity services included, antenatal clinics, maternity assessment unit, day assessment unit, Tangmere ward, which was an antenatal and postnatal ward, midwifery led unit, labour ward, 1 obstetric theatre, 1 high dependency delivery room which was used as a second theatre in emergencies, recovery area and a bereavement suite.

The design and the environment did not effectively meet the needs of women and babies. The service had multiple estates issues which made it difficult for staff to deliver timely clinical care safely and contributed to a more stressful working environment. For example, we saw there was a lack of space in the maternity assessment unit, inappropriate waiting areas for women and insufficient rest areas for staff.

However, following the inspection the service told us there were alternative rest areas available for staff.

The service had birthing pools in the birthing unit and labour ward which were in accordance with best practice guidance and pool nets were also available in the event of a woman requiring emergency evacuation from the birthing pool.

The service lessened the risk of having 1 obstetric theatre by working with the day surgery unit to secure availability for an extra elective case list 1 day a week. The day surgery theatre list was staffed with a separate maternity/obstetric team with 3 registered midwives and a consultant lead. The service planned to extend the day surgery theatre session to 2 days in 2026.

The high-dependency delivery room was a prepared room which could be converted to a second theatre if required in an emergency and if the day surgery unit was not available. The head of midwifery (HOM) had completed an environmental risk assessment to make sure the area was safe for women. A draft statement of purpose (SOP) had been produced for the use of the day surgery unit for elective sections. The SOP was currently going through the governance processes, and this had been shared with staff.

The MAU was small and women attending were required to wait outside in the waiting area where staff did not always have a direct line of sight of the women attending.

The waiting area for women attending the maternity assessment unit (MAU) did not meet national guidance for maternity triage areas. The MAU was in the labour ward, and a separate bell was used to inform MAU staff that they had arrived and asked to remain in the waiting area outside of the labour ward. This was so the service could safely identify who entered the labour ward. However, this meant there was some confusion when women rang the wrong bell for the MAU or labour ward. This had the potential to delay timely access to the appropriate clinical team and initial assessment.

The service had a purpose-designed bereavement area to help support women and their families. The bereavement suite was located on the labour ward and was not fully soundproof, which meant there was a potential for parents to hear sounds from the labour ward and experience distress. A soundproof bereavement suite protects women and families from distressing external noise, supporting privacy, dignity and compassionate care. However, there were no incidents or concerns reported by families relating to the location of the bereavement suite. The bereavement suite was seen to be well equipped and provided a comfortable home environment for women and their families.

The maternity unit was clean, tidy and free of clutter. However, we did find stainless steel storage containers within labour ward which had areas of rust. Rust creates rough surfaces that trap dirt and bacteria, making the containers difficult to clean properly.

Staff completed daily checks on specialist equipment, including the post-partum (PPH) and major obstetric haemorrhage (MOH) trolley in labour ward. The emergency resuscitation trolleys were tagged. Resuscitaires were available on the labour ward and postnatal unit, and we found they were accessible and were well maintained.

Fire exits were clearly marked and unobstructed. There were birth pool evacuation nets and equipment in every room that had a birthing pool and staff completed evacuation of pool training.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met women’s individual needs.

The department recognised the impact of short staffing on the workforce and implemented a new divisional clinical operating model which included overarching cross site clinical director roles for both specialities alongside dedicated site-specific medical leadership.

The trust had recruited 2 full-time band 8a recruitment and retention matrons to support maternity and neonatal services with safer staffing. The perinatal development workforce report identified the current vacancy data across maternity services and what short-term and long-term strategies were being put in place to support staffing.

Student midwives across the trust were offered permanent hours at their chosen location, which would over-recruit against current establishments. However, it was too early for the service to know if this had a positive effect on staffing St Richard’s hospital. Newly qualified midwives completed a 12 to 18-month preceptorship programme, to support them in their role.

The service was currently completing a Birth Rate Plus (BR+) assessment to assess the midwifery and maternity support worker workforce. The report was due to be completed in January 2026. The current staffing model for the service was reflected of the previous 2023 BR+ recommendations.

The October 2025 perinatal workforce report identified that staffing remained stable overall within the service. The BR+ assessment is usually completed every 2 years and is an evidence‑based tool used to determine midwifery staffing requirements based on birth activity and case complexity. It supports safe staffing by ensuring workforce levels are aligned with clinical demand and risks to safe care are identified.

However, staff told us that staffing levels on Tangmere Ward felt unsafe. This was particularly when caring for women undergoing induction of labour and caesarean sections alongside routine antenatal and postnatal care. They reported this was made worse by working below established staffing levels and staff being redeployed to the delivery suite.

There was currently a high maternity vacancy rate. Head of midwifery (HOM) told us that staffing within both Tangmere and the maternity assessment unit were being reviewed in the most recent BR+. October 2025 the midwifery vacancy rate for the service was 9.4%. However, the service had seen an improvement within maternity staff sickness. Various support and well-being offers had been introduced across maternity services including listening events and newsletter updates.

The service had enough medical staff to keep women and their babies safe. St Richard’s Hospital benefitted from a higher number of consultant obstetricians, than the other 3 maternity locations within the trust. The service had consistent consultant presence for twice daily ward rounds.

The service provided mandatory training data for August.2025 only, this included, skills and drills training or fetal monitoring training. The data showed 90.7% of doctors and 95% of midwives were compliant in fetal monitoring. Multidisciplinary (MDT) skills and drills data was not broken down into staffing groups and showed 87.2% compliance. However, we were told there was low compliance from obstetric and anaesthetic teams across the trust for fetal monitoring. Therefore, the clinical director and operational manager were currently developing a plan to address low compliance.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Matrons and ward leaders oversaw infection prevention and control across the maternity department.

All areas in maternity were visibly clean and had suitable furnishings which were clean and well maintained. However, there were large stainless steel storage boxes seen within the labour rooms, the top of the container had visible rust, which made it difficult to clean.

We found cleaning schedules and records were monitored through audit to check for compliance. Staff cleaned equipment after contact with women. Staff used ‘I am clean’ stickers to show equipment was clean and ready for use. Bathrooms and toilets were clean and there were laminated posters explaining hand washing technique.

Privacy curtains were clean and labelled with their replacement date. Staff regularly checked birthing pool cleanliness, and the service had an effective system for legionella testing of the water supply.

Staff followed infection prevention and control principles and used personal protective equipment correctly (PPE). Staff were bare below the elbow, and we observed them cleaning their hands with alcohol-based hand gel. Staff prompted all visitors to clean their hands on entering the department. There was sufficient supply of PPE such as gloves, masks and aprons.

Hand hygiene audits were completed monthly within each clinical area and all areas scored 100%.

We scored the service as 3. The service made sure that medicines and treatments were safe and met women’s needs, capacities and preferences.

The service had medicine administration guidelines for midwives. Midwives had access to the full list of midwives’ exemptions, so they were clear about administering within their remit. Midwife’s exemptions allow registered midwives to supply and administer certain medicines without a prescription, under specific legal and professional conditions.

Staff were trained to administer medicines safely. Staff demonstrated good understanding of how to monitor for and manage medical emergencies that can occur in pregnancy, including post-partum haemorrhages and sepsis. The trust prepared emergency medicines boxes centrally. These were available, tamper evident and in date.

The service reported that maternity services do not complete prescription audits as there had been no identified themes for concern and no recent incidents regarding prescribing.