Worthing 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. We also checked that women’s liberty was protected where this was in their best interest and in line with legislation.

At our last assessment we rated this key question requires improvement. At this assessment the rating remained requires improvement. Although we saw improvements it still meant some aspects of the service were not always safe. This meant people were not always safe and protected from avoidable harm. We assessed 8 quality statements.

The service was in breach of legal regulation in relation to people’s safe care and treatment, the way people’s medicines were managed safely, premises and equipment. The breaches relate to management of environmental risks, medicines management and safeguarding training.

Staff did not always manage medicines well. Staff did not receive the correct level of safeguarding training in line with national guidance. The service did not always manage environmental risks effectively.

However, the service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people and were clean and well-maintained. There were enough staff with the right skills, qualifications and experience.

We have not awarded this service a score for Safe.

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

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

Staff knew what incidents to report and raised concerns and reported incidents and near misses in line with the trust policy. Staff we spoke with could describe what incidents were reportable and how to use the electronic reporting system. A learning channel had been set up on a digital workspace that all staff could access and staff showed us this.

Staff discussed patient safety events monthly at a cross-site safety and quality meeting, including progress on reports and learning (both immediate and longer term). These were chaired by the patient safety midwives or the governance leads. They noted action points and translated them into the rolling meeting action plan.

The trust reported that maternity was the highest reporting clinical service of low and no harm incidents. The department felt this demonstrated a healthy reporting culture and provided opportunities to address concerns raised before harm was caused.

Staff told us that learning from incidents was shared with staff by email and in the maternity ‘message of the week’. We saw the maternity message of the week at the time of our assessment, and this included completing body maps on the electronic system.

Staff knew about after-action reviews, which are a structured process for learning from patient safety incidents by asking set questions. Staff gave examples from the maternity assessment unit where all incoming calls were recorded and were used in after action reviews to help learning.

There was a learning from patient safety board outside the entrance to the delivery suite which had an example of a recent patient safety incident. The example was regarding a failed induction of labour and included the format of situation background assessment recommendation.

Staff told us they had the opportunity to attend patient safety meetings and that their managers took action after incidents. However, there was a mixed response to the level of feedback that staff got after they had reported incidents, with some staff saying they did not get feedback and some saying they only had feedback via email.

The service understood the importance of duty of candour. Duty of candour is a requirement for healthcare professionals to be honest and open with patients when something goes wrong with their care and treatment. Compliance with duty of candour was monitored through the maternity dashboard and showed that 100% compliance was maintained monthly.

The department reviewed all fetal and neonatal deaths using the national Perinatal Mortality Review Tool (PMRT). This was a standardised tool used nationally to review the deaths of babies from 22 weeks gestation onwards, including late miscarriages, stillbirths, and neonatal deaths.

However, some staff were not aware of the Patient Safety Incident Response Framework (PSIRF) which replaced the Serious Incident Framework. PSIRF, is a mandatory framework within the NHS in England for how health services respond to and learn from patient safety incidents. Its main goals are compassionate engagement with those affected, a system-based approach to learning, proportionate responses to incidents, and supportive oversight to improve patient safety systems and culture.

The trust told us that on the 28 February 2025, there were 158 open maternity incidents, including 36 that had been open for longer than 60 days. However, this data was not broken down to site level. Delays in reviewing and closing incidents impacted on the ability to learn from incidents and was a risk to women and babies.

The service engaged with the Maternity and Newborn Safety Investigations (MNSI) programme. They reported 1 incident to MNSI for investigation in the 6 months before the assessment. Managers developed an action plan based on the recommendations. At the time of our assessment 2 out of 3 actions were completed including updated guidance to be shared trust-wide and the outcome to be shared as part of the maternity ‘message of the week’.

The evidence showed some shortfalls. Staff worked with families and healthcare partners to establish and maintain safe systems of care, however safety was not always managed or monitored in line with guidance. The service did not monitor continuity of care of women, including when women moved between different services.

Staff used an electronic triage assessment system to improve the safety of mothers, babies, and the management of the department. Staff promptly carried out a brief assessment (triage) of women who presented with unexpected problems or concerns. They used a standardised way to assess how quickly women needed to be seen.

Women attended the maternity assessment unit (triage) at Worthing Hospital 1242 times from October to December 2024. The most common reason for attendance was reduced fetal movements followed by feeling unwell and suspected labour.

We reviewed the notes of 2 women who had attended maternity assessment unit (triage) and saw that they were seen promptly. Their records had been appropriately updated and ‘red, amber, green’ (RAG) rated.

The trust audited the use of the triage system from (October to December 2024) and showed that 82% of women attending triage had their initial assessment within 15 minutes, which was an improvement from the 2023 audit. However, the audit found that the timings of calls to the obstetric team and their attendance were often not documented. The medical team saw 56% of women within 2 hours. It also showed that 8% of women waited over 4 hours. In 13% of notes there was no documentation of the time of the medical review. The trust had identified an action plan was needed to address the shortfall; however, this had not yet been developed.

There was a dedicated office for triage in the department opposite the maternity assessment unit (MAU). However, this was staffed by only one midwife who had to complete regular observations of patients waiting in triage and answer the door buzzer. Following the assessment, a maternity support worker has been assigned to MAU to support the triage midwife.

CQC coordinates a national survey annually to look at the experiences of pregnant women and new mothers who used NHS maternity services. Data from the CQC Maternity Survey 2024 showed that the trust performed better than the national average against the questions: “thinking about the last time you were triaged, did you feel that your concerns were taken seriously by the midwife or doctor you spoke to?”, the service scored 8.8, which was above the national average of 8.4 when compared to all other trusts in England.

Women who underwent an induction of labour at Worthing Hospital accounted for on average 32.7% of births from January 2024 to January 2025. It was reported that the total number of women with a blood loss of over 2500ml averaged 3.5%. The trust did not set a target, for expected outcome figures to check for outliers, identify any increases or trends in numbers.

The service did not monitor continuity of care data. Continuity of care where a woman has a dedicated midwife or team throughout their pregnancy, labour and postnatal period is important for improving outcomes and experiences. Following the assessment, the trust told us that the service did not have continuity of care teams at Worthing and therefore no data was collected. They told us that vulnerable women and those at risk of health inequalities were offered enhanced antenatal and post-natal continuity.

The service had 100% compliance with National Institute for Health and Care Excellence (NICE) guidance on Intrapartum care - Quality statement 2: One-to-one-care. This measured whether women had one to one care during their labour and birth. This increased the likelihood of a positive birth experience for the woman.

Staff of all grades attended regular safety huddles where they shared safety information.

Medical and midwifery teams had handover meetings at shift changeover to discuss all women in the maternity unit.

During the assessment we attended several handover meetings and safety huddles. We found them well attended and used to fully discuss the patients and concerns.

Women who were between 5 and 14 weeks pregnant and had concerns about their pregnancy could access care in the early pregnancy unit (EPU). The EPU was open between 8am and 2pm Monday to Friday. From 2pm to 7:30pm women were advised to contact the gynaecology day unit.

Women’s notes were clear, and staff could access them easily. Staff used both paper and electronic notes with critical information duplicated in both. We reviewed 5 patient records and found them to be detailed and completed correctly. Staff added to the records in real time so any health professional accessing the notes had the most up to date information about the patient. Records were stored securely. All computers were password protected, and staff locked the terminals when not in use.

The service monitored their avoiding term admissions into neonatal units (ATAIN) rates which for January 2025 was 0.6%. Between February 2024 and January 2025, the average rate for Worthing Hospital was 1.96%. All babies who needed special care or transitional care were discussed at an ATAIN meeting. An ATAIN meeting focuses on reducing unnecessary admissions of full-term babies to neonatal units by identifying and addressing potential issues.

The evidence showed some shortfalls. The service generally worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that. Staff had some training on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They generally shared concerns quickly and appropriately.

Not all staff received the right level of training on how to recognise and report abuse. Midwives were not trained to the appropriate level of safeguarding training. The Royal College of Nursing Adult Safeguarding: Roles and Competencies for Health Care Staff sets out that health care staff engaged in assessing, planning and delivering care, should all be trained to level 3 safeguarding adults. Data showed that no midwifery staff were trained to this level.

The trust set a target of 90% for all mandatory staff training. Records at the time of assessment showed 89% of midwives had received level 3 safeguarding training in children and young people and 73% of medical staff had received this. Also 100% of medical staff had received level 3 training in safeguarding adults.

The trust had appropriate safeguarding policies that aligned with national guidance and a designated safeguarding midwife. Staff understood specific safeguarding issues that were related to maternity services and newborn care. These included female genital mutilation (FGM), child sexual exploitation (CSE) and coercive control.

Staff worked with people and healthcare partners to understand what being safe meant to them and how to achieve this. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff identified abuse and knew how to report their concerns to the safeguarding team. Staff used electronic systems to raise concerns. Staff placed a flag on women’s records if safeguarding issues were identified. This included staff in the emergency department and the early pregnancy unit (EPU). This allowed staff to easily identify women or babies at risk. High risk concerns were shared with safeguarding midwives who supported staff with the referral and any actions.

Staff described a supportive and available safeguarding team. The safeguarding midwife visited the wards daily and the wider team were always available for advice. The safeguarding team also had clear escalation pathways and reported to the board via the hospitals safeguarding lead.

Staff completed psychosocial risk assessments for women considered to be at risk of self-harm. For example, staff used a purple flag to show women that may need mental health support, and this would flag up on the screen when entering the record. Safeguarding training included information about domestic abuse, and how staff could refer women to a service provided by the local council that supported people at high risk of harm because of domestic abuse. We reviewed 5 patient records and saw that staff had documented that they asked all 5 women about the risk of domestic violence.

Specialist midwives supported women with protected characteristics including women from traveller communities.

The service held monthly multi agency maternity safeguarding sessions to discuss management of women in the coming months. The local authority, social workers, and wider stakeholders such as family members attended.

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

Staff used cardiotocography (CTG) to monitor babies' wellbeing. A CTG is used to monitor the fetal heartbeat and uterine contractions during pregnancy and labour and can identify if a baby is in distress. The service had a policy and process for the recording, annotating and storage of CTG traces.

The trust had a policy outlining the frequency and review process for CTG (including fresh eyes) to minimise interpretation errors and to ensure optimum fetal monitoring. We reviewed 5 sets of notes, 3 of which required CTG monitoring. All 3 had fresh eyes performed and appropriate documentation at beginning and end.

The trust carried out a CTG Fresh Eyes Deep Dive audit in November 2024. The audit found inconsistency in documenting, reporting and recording of ‘fresh eyes’ across the trust. At Worthing Hospital, 90% of CTGs had been reviewed, but only 76% had ‘fresh eyes’ documented. Recommendations were identified as a result of this audit, however action plans had not been developed at the time of our assessment. Following the assessment, the trust told us that the audit fed into the Saving Babies Lives action plan. They told us that the main action was to update the Intrapartum Fetal Heart Monitoring guideline, which was updated in October 2025.

Staff used nationally recognised tools, such as the modified early obstetric warning score (MEOWS) and the newborn early warning trigger and track (NEWTT2) tool, to identify women and babies at risk of deterioration and escalated them appropriately. We observed that women’s MEOWS were colour coded appropriately in the notes we reviewed. Colour coding is used to categorise risk, with green/white indicating normal or low risk, yellow for mildly abnormal or increased monitoring, and red for severely abnormal or immediate medical review. However, as the trust did not currently audit the use of either of these tools, it was not clear whether these tools were being used correctly for all women.

The service held consultant-led labour ward rounds twice daily, 7 days per week. Consultants also attended a weekly multidisciplinary meeting (MDT) for the early pregnancy unit (EPU) where complex cases were discussed.

We reviewed 5 records from women who attended triage. Staff had documented full assessments, including time of arrival, time seen and a red, amber, green (RAG) rated assessment to show acuity.

The service had a seated waiting area for women arriving to the department. When this area was full, women waited in the gynaecology area. Staff used a whiteboard to keep track of where women were, however this meant that patients were not in the triage area, and reliant on already busy staff updating the whiteboard.

Staff undertook emergency birthing pool evacuation in the event of an emergency. Data showed 79% of midwives had completed the training but only 63% of nursery nurses and maternity care workers had completed the training.

Staff did not always use the Whooley Depression Screening tool to identify women with depression. We noted that 3 out of the 5 records we reviewed contained a Whooley Depression Screen, this meant that not all women were receiving this screen.

Staff used national tools to assess women during the antenatal period. A full assessment was completed at their booking appointment (the first full assessment at the beginning of the pregnancy).

Staff carried out risk assessments for women using a standardised risk tool in line with national guidance. These included social assessment, risk assessment for blood clots and mental health assessment. Women’s communication methods were also included in initial assessments to ensure they could access the right care and communication.

The service had access to mental health liaison and specialist mental health support. Staff gave women information on where to get support for mental health concerns.

The service had an Early pregnancy unit (EPU) that saw pregnant women with pain or bleeding in early pregnancy (between 5 and 18 weeks). Women could walk in or be referred by their GP or the emergency department.

The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. Staff did not make sure that equipment, facilities and technology supported the delivery of safe care.

The service had only 1 dedicated obstetric theatre that staff used for both planned and emergency caesarean sections. This failed to meet national guidance which required 2 obstetric theatres to be available. This was documented on the trust risk register with a mitigation of using the emergency theatre in main theatres when needed. This meant that an emergency caesarean section could disrupt planned caesarean sections. Also, if 2 women needed emergency caesarean sections at the same time, 1 woman would have to be transferred to the emergency theatre in main theatres, causing a potential delay to emergency treatment. We did not receive information on how many times this had occurred. There was a project underway trust-wide to implement second theatres for each maternity service on each site.

The service did not always detect and control potential risks in the care environment. A patient safety alert issued in 2020 highlighted that services providing mental health care routinely develop environmental improvements and safe management during clinical care to reduce the risk of self-harm or suicide. Staff told us that ligature risk assessments had not been completed and someone had been tasked to look at this trust-wide. We saw ligature risks such as non-detachable pull cords in some areas in maternity. Staff told us they try to mitigate the risk by checking women regularly, and that there was a ligature cutter stored safely and available to staff if needed. We requested evidence of environmental ligature and ligature point risk assessments and we were not immediately provided with this. There was no evidence of this being documented on the risk register. Following inspection, we were provided with evidence that risk assessments of Bramber and the delivery suite had taken place in July 2025.

An audit showed that 82% of women were triaged within 15 minutes at Worthing Hospital. Due to the size of the triage waiting area women had to wait elsewhere in the department if several women attended at the same time. Staff used a whiteboard to track the whereabouts of these women but told us this was not ideal.

Women and families could spend time in the bereavement suite after delivering a baby who had died. The suite had specialist equipment such as cold cots, which allowed the family to spend several days with their baby after death. The suite was equipped with a bed, and kitchen facilities to allow families to spend time there as comfortably as possible.

The service had moved the bereavement suite from near the labour ward to opposite the triage waiting area to try and reduce the distress of hearing other mothers in labour. The new location meant that bereaved parents were still near expectant mothers. Staff understood that this could be distressing for bereaved parents however the department had limited areas available. To try and lessen any noise transfer, the bereavement suite had two sets of doors.

The service also had a ward area, labour ward and recovery area. The unit was fully secure with a monitored entry and exit system. A ward clerk was available until 4:30pm, after this, maternity assistants covered ward clerk duties. The antenatal clinics were in a separate area of the hospital.

The service had considered the use of patient areas. The unit was visibly clean, tidy and free of clutter. Fire exits were clearly marked and unobstructed. New flooring was being fitted on Bramber Ward at the time of our assessment.

Staff disposed of clinical waste safely. They segregated waste correctly and stored it securely while awaiting disposal. Staff assembled sharps bins correctly and we saw these were signed and dated.

The service ensured regular checks of specialist equipment, including resuscitaires and resuscitation trolleys. We saw that emergency trolleys were well stocked and organised.

Staff had enough specialist equipment such as CTG machines. At the time of our assessment 2 CTG machines had broken and were awaiting replacement. Staff told us there was a good process for the reporting and replacement of broken equipment.

The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff. Managers provided support, supervision and development. Staff worked well together to provide safe care that met people’s individual needs.

The service had enough medical staff to keep women and their babies safe. Data showed that there was always obstetric cover on the delivery suite. This meant that there was always a qualified obstetrician available to support with births if medical intervention was needed. The service had 12.8 whole time equivalent (WTE) consultant obstetricians and no vacancies.

The department leadership told us they were compliant since September 2024 with the Ockenden review recommendations for ‘consultant present’ ward rounds day and night.

The service used an escalation policy to provide guidance when the staffing did not meet patient acuity. However, ward co-ordinators, who should have been supernumery to manage the unit were sometimes called on to provide one-to-one care to women in established labour. The service considered this a ‘red flag’ incident.

The service monitored how often this happened and reported this at monthly divisional governance meetings and maternity safety champion meetings. Between September 2024 and February 2025 there were 7 episodes of one-to-one care provided by labour ward co-ordinators.

The service used a standard operating procedure that clearly set out the number of midwifes required on each shift. The trust told us that four maternity support workers were needed per shift. The service used a specific workforce tool based on patient acuity which was updated every 4 hours to determine staffing requirements.

The service had no midwife vacancies in January 2025. This was improved from 2024 when vacancy rates ranged from 8% to 15%.

The service had an average sickness rate for midwifery staff of 9.61%, from January 2024 to January 2025.

New staff were required to undertake a local Induction as well as statutory and mandatory training. Clinical staff were required to undertake an appropriate clinical induction which incorporated basic life support, manual handling and emergency situations. Competency assessments were then undertaken and signed off by line managers.

The service made sure staff were competent for their roles. Managers appraised staff performance and held supervision meetings, providing support and development. The appraisal rate for the maternity service at Worthing Hospital was 93%. Newly qualified midwives had a 12 to 18-month preceptorship program, which supported them to integrate newly registered midwives into their new team and place of work. The trust provided Practical Obstetric Multi Professional Training (PROMPT) which is an evidence based multi professional training package for obstetric emergencies. Records showed that 96% of midwives had completed this, and 100% of nursing staff. However, the figures were lower for nursery workers, maternity support workers, obstetricians and anaesthetists who only showed between 80% and 90% compliance.

Staff received cardiotocography (CTG) training and records showed that 95% of midwives had completed this training, and 96% of obstetricians. CTG is used before birth and during labour to monitor the baby for any signs of distress via their heart rate and contractions.

Staff received newborn life support (NLS) training to make sure they were able to effectively manage the resuscitation of a newborn infant. Records showed that 100% of nursing staff, 96% of midwives and 90% of nursery nurses and maternity support workers had completed the training. However, compliance was lower for obstetricians and anaesthetists at 81% and 80% respectively.

The service had achieved 100% implementation of the saving babies lives care bundle in June 2024. The service met the requirements of the Clinical Negligence Scheme for Trusts (CNST), Maternity Incentive Scheme. The requirements were met for year 5 and the trust was on track to meet the requirement for year 6.

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

The maternity unit had suitable furnishings, was visibly clean and well maintained. Staff cleaned equipment after contact with women. Staff used ‘I am clean’ stickers to show equipment was clean and ready for use.

Maternity assistants were responsible for cleaning equipment in between patients. Housekeepers completed daily cleans of the department and delivery suite after a woman’s delivery and transfer to a different area. Staff told us that they could contact the housekeeping team for cleaning required overnight.

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.

Staff told us they completed mandatory training on infection prevention and control annually, we saw most staff groups had completed this. Compliance for yearly updates were 91% for midwives, with medical staff compliance lower at 73%, which was lower than the trust target.

Staff across the unit told us they carried out infection prevention and control assurance audits weekly. We saw compliance of 80% in December 2024 and 100% in January 2025. However, compliance was as low as 25% for most of 2024, which the service did not provide an explanation or context for. Following the assessment, the service told us that there had been challenges in 2024 and that there had been improvements in 2025. We noted that the results for January and February 2025 had improved to 100%.

The service completed monthly hand hygiene audits. The data showed 100% compliance for 9 out of 11 months. However, we noted the score was not recorded for the remaining 2 months, which suggested the audit had not been completed. The trust only provided data for the labour ward and not the other areas of maternity.

The evidence showed some shortfalls. Across the maternity service we identified concerns with the management of the stock medicines. However, processes were in place for the secure storage of medicines including controlled drugs and medical gases.

We identified areas of concern which included a lack of revised expiry dates when a medicine was opened or moved from fridge to room storage. We also found cut blister strips lacking the name of the medicine, expiry date and or batch number.

We looked at fridge temperature records which showed that on occasions the maximum temperature was out of range. There was no evidence that this had been escalated or investigated in line with the trust procedures.

The service had locally prepared emergency medicines boxes. These were available to support staff manage deteriorating patients suffering from common conditions associated with pregnancy. However, the preparation of these boxes lacked governance and oversight resulting in variation in content and labelling.

Over-labelled medicines were available for staff to supply against discharge prescriptions. However, the quality of the over labelling of the medicines in the to take out (TTO) cupboard was variable including inappropriate over labelling, labelling obscuring the directions or incomplete labelling. Therefore, there was a risk that patients on discharge may receive medicines with incomplete labelling and directions.

Processes were in place to monitor staff exposure to nitrous oxide working in the delivery suite.

Staff followed trust guidance to support the record keeping of controlled drugs. The controlled drugs register we reviewed showed staff were following trust guidance. However, staff were not consistently following trust guidance and processes for the safe management of controlled drug stationary. This meant there was an increased risk that the loss of controlled stationary would not be identified.

Legislation supported by trust guidance allowed midwives to administer of supply an agreed list of medicines via "midwife exemptions" and patient group directions (PGDs). Of 6 PGDs we reviewed, 1 national PGD had been approved for local use as the next national version was released, resulting in the locally approved version being past its expiry date at the time of the inspection. We received conflicting information about a further national PGD that the clinicians wished the midwives to have access to that had not been adapted and approved for local use.

We found that only an ad-hoc clinical pharmacy service was provided to maternity services. Therefore, risk-based pharmacy support was not available to support high risk pregnancies with pharmaceutical care plans, or to undertake medicines reconciliation, supporting safe medicines use in breastfeeding post-partum, clinical screening of discharge prescriptions and timely transfer of medicines.