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 people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating remained requires improvement. This meant people were not always protected from avoidable harm. We assessed all quality statements under this key question.

At the previous assessment, 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 related to management of ligature risk assessments, medicines management and safeguarding training. We found areas of improvement in relation to the breaches. However, the service remained in breach in relation to safeguarding training. The service was also in breach of legal regulation in relation to environmental risk assessments.

Although we saw some improvement, the service did not consistently ensure safe care. The service did not consistently identify, monitor and mitigate environmental risks, and did not always ensure equipment was available, safe or appropriately cleaned for use. Staff did not always have evidence of completing required training. Staff did not always manage medicines safely.

However, the service demonstrated some areas of strength. Staff supported a positive safety culture where people could raise concerns, and managers investigated incidents thoroughly. The service generally kept people safe, and leaders ensured there were enough staff with the right skills, qualifications and experience to meet people’s needs.

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

Staff understood which incidents to report and raised concerns appropriately. They reported incidents and near misses in line with trust policy and clearly described what was a reportable event. Staff demonstrated how they used the electronic incident reporting system effectively. The service had introduced a digital learning channel that all staff could access, and staff showed us how they used this to share learning.

Staff discussed patient safety incidents at monthly cross-site safety and quality meetings. They reviewed progress on investigations, shared learning, and agreed both immediate actions and longer-term improvements. Patient safety midwives or governance leads chaired these meetings. They recorded actions and included them into a rolling action plan to support ongoing improvement.

The governance team reviewed incidents through a rapid review process. They identified immediate risks and implemented actions to reduce potential harm to women and babies.

The service promoted learning through visible communication. Staff displayed patient safety information on boards within the delivery suite, including examples of recent incidents, outcomes and key learning points. This supported staff awareness and encouraged shared learning across the team.

The service understood and applied the principles of duty of candour. The duty of candour is a professional obligation for healthcare providers to be open and transparent with patients when something goes wrong in their care. Leaders monitored compliance through the maternity dashboard, which showed the service consistently achieved 100% compliance each month. This showed that staff were open and honest with women when things went wrong.

The department reviewed all fetal and neonatal deaths using the national Perinatal Mortality Review Tool (PMRT). This standardised approach ensured staff reviewed deaths consistently and identified learning to improve care.

The service analysed incidents over the previous 12 months and identified recurring themes. Data showed that the most common incidents related to delays in category 1 emergency caesarean sections, third- and fourth-degree perineal tears, and postpartum haemorrhage greater than 1500mls. These trends highlighted areas where clinical risks occurred most frequently. Whilst the service had noted these trends, there was a delay in actions and learning.

The service reported 1 never event in the year prior to inspection relating to the implantation of the incorrect contraceptive device in theatre. A never event is a serious, preventable medical error that should never occur in healthcare settings. Leaders carried out a patient safety investigation and identified actions to reduce the risk of recurrence. These actions included plans to audit compliance with the World Health Organisation (WHO) safety checklist to help strengthen patient safety practices. The WHO Surgical Safety Checklist is a 19-item tool designed to improve surgical safety, reduce complications, and enhance teamwork and communication in operating rooms. Another site within the trust had piloted a revised approach to the checklist, which leaders planned to roll out at Worthing. This showed that leaders responded to serious incidents and had begun to implement improvement actions, although changes were not yet fully embedded at the time of inspection.

However, the service did not always act on learning in a timely way. Leaders told us they had planned a thematic review of postpartum haemorrhage, which was a known area of risk. The service had delayed this work due to staffing pressures and competing national audit priorities. At the time of inspection, leaders had scheduled the review to begin in April 2026. This meant the service had not yet completed detailed analysis or implemented targeted improvements for a key risk area.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The service did not always operate effective systems to protect women and babies from harm. For example, delayed checking of a test result had happened due to ineffective processes for following up results. This resulted in harm of a patient. The departmental risk register included how staff did not have a single, standardised pathway across all 4 hospital sites to record and follow up blood and microbiology results. This risk had remained on the register since 25 September 2024, which showed that leaders had not resolved the risk in a timely way.

The service had not been operating a continuity of care model for some time due to wider service pressures. This had remained on the risk register since July 2022. The service noted not all women, including those who may have benefited most, consistently received care from the same team of midwives. Leaders told us they had developed a new business case to reintroduce a continuity model for vulnerable women. A start date for implementation had not yet been confirmed.

Staff maintained effective systems to support patient safety. Staff of all grades attended regular safety huddles where they shared key safety information. Medical and midwifery teams also held structured handover meetings at every shift change to discuss all women receiving care. During the assessment, we observed several handovers and safety huddles. Staff attended these meetings consistently and used them to discuss patient needs and risks in detail.

The service achieved 100% compliance with National Institute for Health and Care Excellence (NICE) guidance on intrapartum care, specifically quality statement 2 relating to one-to-one care during labour and birth. This supported safer care and improved the likelihood of a positive experience for women.

The trust audited the use of its telephone maternity triage system. During March 2026, staff answered 3,108 calls across all 4 sites, with Worthing Hospital accounting for 891 calls. Staff answered calls within an average time of just under 3 minutes. While there is no national standard for maternity triage call answering times, this showed the service monitored telephone triage performance and responded to a high volume of calls. The service had identified that staff answering maternity triage calls were not supported by standardised advice scripts. Leaders had recorded an action to develop standardised telephone triage guidance aligned with national recommendations. This action had a deadline of September 2026.

CQC coordinates a national maternity survey each year to understand the experiences of pregnant women and new mothers using NHS maternity services. We reviewed the findings from the 2025 maternity survey.

Results showed the service performed better than the national average in key areas relating to triage. When women were asked whether they received the advice they needed the last time they contacted the telephone triage line, the service scored 8.9 compared with a national average of 8.3. When asked whether the midwife or doctor listened to them during their most recent face-to-face triage attendance, the service scored 9.1 compared with a national average of 8.7.

These results showed that staff communicated effectively and responded positively to women’s needs when accessing triage services.

We scored the service as 2. The evidence showed some shortfalls. 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.

Since the last assessment, leaders had introduced mandatory Level 3 safeguarding adults training in line with national guidance. However, they had not implemented this in a timely way. Training for some staff commenced in March 2026, with compliance for all relevant staff not expected until March 2027. Leaders told us that achieving full compliance across the multidisciplinary workforce would take time because only a limited number of staff could be released from clinical duties at any one time to maintain the safety of the service. We requested an update on compliance levels following the inspection, the trust did not provide this information.

Training data showed that midwives achieved 90% compliance with safeguarding children and young people level 3 training, which met the trust target. Medical staff compliance was slightly lower at 86%, but this had improved since the previous assessment.

The service showed a structured approach to safeguarding practice. The service had safeguarding policies that aligned with national guidance and had appointed a designated safeguarding midwife to lead this area. Staff showed a good understanding of safeguarding risks relevant to maternity and newborn care, including female genital mutilation (FGM), child sexual exploitation and coercive control.

Staff worked collaboratively with women and partner agencies to understand individual risks and promote safety. They focused on improving outcomes while protecting women from abuse, discrimination, avoidable harm and neglect. Staff shared safeguarding concerns appropriately and without delay.

Staff completed psychosocial risk assessments for women identified as being at risk of self-harm. They used a ‘purple flag’ system to highlight women who required mental health support, and this alert was clearly visible within care records to ensure staff awareness.

Staff completed safeguarding training that included recognising domestic abuse and understanding referral pathways to local authority services for individuals at high risk. Most records we reviewed showed that staff routinely asked women about domestic abuse, which supported early identification of risk.

Staff took part in baby abduction simulation exercises led by safeguarding and practice development teams. Teams told us they planned to develop a learning video from these exercises and upload it to a staff learning platform to support wider learning

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

The service did not consistently show how it involved women in managing risks or used data to ensure safe, personalised care. The service collected data on the number of women who underwent induction of labour. Data showed that, between September 2025 and February 2026, an average of 33% of women received an induction. However, the service did not collect or monitor waiting times for induction of labour. This meant they were unable to fully identify or respond to delays, which could increase risks to women and babies. The lack of oversight limited the service’s ability to ensure women received timely information and care to support informed decision-making.

The service had not audited the use of key safety tools, including the modified early obstetric warning score (MEOWS) and the newborn early warning trigger and track (NEWTT2). We identified this gap at the previous assessment, and it had not been fully addressed at the time of this inspection. Although leaders told us they had scheduled a MEOWS audit for July 2026 alongside the introduction of a new tool to support compliance, they had not completed the audit at the time of the assessment. This meant leaders did not have effective oversight to ensure staff used these tools consistently or correctly across all areas.

We identified this concern at the previous assessment, and the service had not fully addressed it at the time of this inspection. Although leaders told us they had scheduled an audit for July 2026 alongside the introduction of a new tool to support compliance, they had not acted in a timely way. As a result, leaders did not have effective oversight of whether staff used these tools consistently and correctly across all areas.

We identified this concern at the previous assessment, and the service had not fully addressed it at the time of this inspection. Although leaders told us they had scheduled an audit for July 2026 alongside the introduction of a new tool to support compliance, they had not acted in a timely way. As a result, leaders did not have effective oversight of whether staff used these tools consistently and correctly across all areas.

Although staff used these tools to identify and escalate deterioration, they did not always complete or escalate observations in line with policy. We reviewed 11 sets of care records, including MEOWS charts, and found that 3 showed delays in escalation and incomplete observations. This showed staff did not always recognise or respond promptly to clinical deterioration and limited the service’s ability to ensure timely identification and management of risk. This meant leaders could not be assured that all women and babies received safe and effective monitoring.

Staff used nationally recognised tools to assess women throughout the antenatal period and completed comprehensive booking assessments. They carried out risk assessments in line with national guidance, including social, venous thromboembolism (VTE) and mental health risks. Staff also recorded women’s communication needs early, which supported their involvement in care and decision-making.

Results from the 2025 CQC maternity survey showed that 261 women provided feedback, and the trust performed in line with other trusts when women were asked whether they received appropriate information and advice about the risks of induced labour. This showed that staff generally supported women to understand risks and make informed choices.

Staff used cardiotocography (CTG) appropriately to monitor fetal wellbeing. The service had clear policies for the recording, annotation and storage of CTG traces. Staff followed guidance on CTG review, including the use of ‘fresh eyes’ assessments, which reduced the risk of misinterpretation.

The service had introduced central monitoring of CTG traces, which allowed staff to review monitoring in real time from a central location. This improved oversight, particularly in areas where women were not receiving one-to-one care.

Audit data showed improvement in practice. A September 2025 audit showed 99% compliance with overall CTG reviews and 94% compliance with ‘fresh eyes’ reviews, showing significant improvement from the previous year.

Staff supported ongoing risk discussion through structured clinical oversight. Consultants led labour ward rounds twice daily, seven days a week, and attended weekly multidisciplinary meetings in the Early Pregnancy Unit to review complex cases.

Staff consistently used the Whooley Depression Screening tool and completed this across all records we reviewed, which showed improvement since the previous assessment. The service also provided access to specialist perinatal mental health support and gave women information about how to access help, which supported early identification and management of risk. The Whooley Depression Screening Tool is a short set of questions used to identify people who may be experiencing symptoms of depression and who may need further assessment or support.

There was an Early Pregnancy Unit which improved access to care for women experiencing complications. Women could attend via referral or as a walk-in, which supported timely assessment and intervention.

We scored the service as 2. The evidence showed some shortfalls. 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 did not always maintain effective oversight of environmental risks. Gaps in equipment management, estate maintenance, environmental design and resource availability meant leaders could not demonstrate that staff consistently identified and managed risks to keep people safe.

The service did not always manage environmental and equipment risks consistently, which limited its ability to ensure safety across all areas.

The design and layout of some areas did not support safe, private or dignified care. In triage, maternity assessment and day assessment areas, staff did not have access to dedicated assessment rooms for women attending triage. Women and their families waited in the corridor area which also served as a waiting room. This area got crowded when busy which meant women and whoever attended with them had to stand. Leaders told us this area had not been risk assessed. We observed women on beds being wheeled through the corridor and saw women waiting, having to move to allow the bed through. This put people at risk of potential harm in an emergency. Leaders told us they were working with estates colleagues to find a solution to this issue.

The bereavement suite was directly opposite the maternity assessment area. Although leaders installed noise-reducing doors, this did not fully reduce the potential impact on families using bereavement services. However, the bereavement suite provided a calm, private and supportive environment. Staff designed this area as a self-contained space, including a kitchen, seating area and cold room, which met the needs of families experiencing loss.

Staff did not consistently following procedures to check and maintain equipment. We found items of sterile equipment that were past their ‘use by’ date in various areas, including the antenatal clinic, postnatal ward and the bereavement suite. This meant that staff could not be sure that the items remained safe and effective for clinical use, which increased the risk of equipment failure and potential harm to women and babies This was escalated during the assessment and rectified.

Although staff stored emergency equipment across the unit and completed routine checks, they did not consistently stock resuscitation trolleys in line with expected standards. The resuscitation trolley in the antenatal clinic did not contain suction equipment or a defibrillator. The trolley on the postnatal ward did not include a defibrillator. Whilst there were emergency trollies that were stocked appropriately near the antenatal clinic, they were down a corridor or through a key card access door. This meant staff may not have been able to access essential life-saving equipment immediately, which could delay emergency treatment. We escalated our concerns during the assessment and was told that the emergency trollies had been rectified to contain the standardised equipment that was missing.

Staff told us they did not always have sufficient cardiotocography (CTG) machines available in the antenatal bay. This limited their ability to carry out CTG monitoring when required. During inspection, we observed only 2 CTG machines in this area, while leaders confirmed there should have been 4. Leaders were not aware of this risk prior to inspection, which showed gaps in oversight and monitoring of equipment availability.

Following escalation, leaders took action to address this. They added the risk to the departmental risk register and submitted a request for additional funding to secure further CTG machines to address the shortfall.

The service did not always have effective processes to manage estate issues. Windows on the postnatal ward were broken and could not be opened, despite staff escalating the issue over a prolonged period. This reduced ventilation and impacted patient comfort, particularly during warmer weather.

The service had 1 dedicated obstetric theatre within the maternity unit. Staff also had access a second theatre in the main theatre department via an emergency lift. However, the second theatre was located further from the delivery suite, increasing the risk of delays when responding to obstetric emergencies. Data provided by the service showed that delayed emergency caesarean sections were the most common incident theme during the 12 months before the assessment. It was not clear if any of the incidents were related to the location of the second theatre. Despite access to a second theatre, the service had not fully lessened the risk of delays in emergency surgical intervention, which could affect outcomes for women and babies. There was a continuing project trust-wide to implement second theatres for each maternity service on each site.

Ward and department areas we visited were clean and had suitable furnishings which were clean and well-maintained. We observed consistently good standards of cleanliness across all core areas, including the antenatal and postnatal wards, delivery suite, labour ward, antenatal clinic and bereavement suite. The service used furnishings suitable for clinical environments, including wipe-clean surfaces, which supported effective infection prevention and control. Cleaning audits showed high levels of compliance across the department, providing assurance that staff maintained cleanliness standards. Staff cleaned birthing pools in line with guidance.

Fire exits were clearly marked and free from obstruction, which supported safe evacuation.

Waste was segregated correctly and stored securely while awaiting disposal. Staff assembled sharps bins correctly and we saw these were signed and dated.

Leaders were aware of many of the concerns, and staff escalated issues appropriately. Although leaders had not always acted in a timely or fully effective way, they recognised the risks. This showed developing oversight and increasing focus on improving environmental safety.

The service was previously in breach for legal regulation safe care and treatment in relation to ligature risk assessments. The service was no longer in breach in relation to this.

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 people’s individual needs.

The service was fully recruited for midwifery posts compared to a national and regional vacancy rate of 3.2%. The service stopped using agency staff in November 2025. Any staffing gaps were covered by bank staff. The turnover of midwifery staff for the service was 4.5% trust wide; this was lower than the 6.1% national rate.

Data showed that demand and acuity had increased significantly over the previous 3 years. Leaders told us they were seeking additional investment in staffing to meet national requirements. They expected this to be supported by the trust board.

The service had arrangements in place to escalate staffing issues. Matrons led twice daily safety huddles to review staffing versus acuity. This information was shared daily across sites with senior leadership. The service had an escalation policy for staffing that covered redeployment of staff, escalation to on-call senior managers and last resort site transfers.

The service previously employed registered nurses to support with patient care on the postnatal ward. At the time of inspection, the ward had redeployed the nurses out of the maternity service, due to a significantly improved workforce position. It was not a requirement to have registered nurses on maternity wards. The service employed nursery nurses that supported care of infants, including transitional care, communication, infant feeding and infant observations. Staff we spoke with told us they had been disappointed to see the adult nurses leave, but valued the support provided by nursery nurses.

The service offered community emergency drills training alongside a local ambulance service. Staff spoke highly of this training. Spaces were limited and attendance had to be rotated to capacity limits. However, leaders told us that community staff received emergency drill experience within mandatory training and that simulated home environments were used.

Staff were mostly up to date with mandatory training. Midwives had a high compliance rate for cardiotocography (CTG) training at 92%. Obstetric doctors were below trust target for this training at 83%. The average compliance for obstetric emergency training (which included neonatal life support and adult basic life support) for midwives, obstetricians and anesthetists was below trust target at 77%. However, trainee anesthetist’s compliance for this training was 57% which lowered the overall average score. Leaders had highlighted this and told us there was an improvement workstream in place and were expected to meet compliance by July 2026.

The service provided pool evacuation training for midwives to support the safe care of women using birthing pools during labour or for pain relief. Compliance with this training was 89%.

The service used a standard operating procedure that clearly set out the number of midwives required on each shift. The trust told us that 4 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. We requested both planned and actual staffing data following the assessment. The data showed an upward trend in 2025. Leaders told us that although staffing was on a positive trajectory, workforce pressures were persistent. Leaders shared this was because of sickness, parental leave and low morale.

Data provided did not show how many vacancies were present for medical staff at Worthing Hospital. However, trust-wide data showed there were just under 20 whole-time equivalent (WTE) vacancies for obstetric and gynaecology medical staff.

Leaders reported ongoing recruitment of middle grade and foundation year doctors across all hospital sites. They also told us they were developing a business case to convert 2 middle grade posts to specialist, associate specialist and specialty (SAS) doctor roles to address identified shortfalls.

Although the service had sufficient staffing overall, it did not organise a dedicated elective team or medical cover for elective (planned) caesarean sections separately from emergency care. This meant that, in the event of an emergency, the doctor undertaking the elective procedure may have had to respond, which could delay the elective caesarean list or could have contributed to the noted delays of emergency caesarean sections. This arrangement created a risk to the timeliness of planned care and highlighted a lack of clear separation between elective and emergency pathways.

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.

The maternity unit had suitable wipe clean furnishings, was visibly clean and well maintained. Staff cleaned equipment after each use, with “I am clean” stickers showing items as clean and ready to use.

Maternity assistants were responsible for cleaning equipment in between patients. We spoke to housekeeping staff who completed daily cleans of the department.

Alcohol-based hand rub was available across the wards and there were sufficient supplies of PPE, (Protective Personal Equipment), to support safe care.

Staff followed infection control principles, including handwashing and use of appropriate PPE. We saw staff completing hand hygiene in line with guidance and staff were bare below the elbows.

Audit data supported compliance with infection prevention and control (IPC). Between February 2026 and April 2026, hand hygiene audits showed consistently high compliance across all maternity areas, with overall scores near or at 100%.

Cleaning audit compliance scores were also high, typically between 98% and 100%, demonstrating sustained adherence to IPC standards. Issues around cleanliness were highlighted by staff when noted and communicated with the housekeeping team. These issues were dealt with in a timely manner.

Although compliance was generally high, we saw some equipment that had not been cleaned in line with protocol. Some equipment had ”I am clean” stickers dated September 2025, so staff could not be sure when it had last been cleaned and made ready for use. We raised this with leaders during the site visit. We also observed 2 staff members not adhering to the bare below elbow policy.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Since our previous assessment, the service had not consistently ensured safe and effective medicines management systems were fully embedded.

The service did not always manage medicines safely. Staff did not consistently monitor medicine fridge temperatures in line with trust policy. We found records of temperatures outside the required range without evidence of escalation or investigation. This showed that staff did not always follow processes to ensure medicines were stored safely.

Staff did not consistently complete controlled drug records. Although the service had updated procedures for the recording and disposal of epidurals containing controlled drugs, staff did not always record disposal activity. This limited the service’s ability to maintain accurate oversight of controlled drugs.

The service used an electronic prescribing and medicines administration system (ePMA). However, analysis of prescribing data from March 2026 showed that 17% of prescribed medicines did not have clear records of administration. Entries were recorded as “unable to confirm administration” or “not charted prior to discharge.” This meant leaders could not be assured that people always received their medicines as prescribed.

The service had not fully addressed concerns identified at the previous inspection regarding the governance of locally prepared emergency medicines boxes used to treat deteriorating patients. Although leaders had developed an alternative solution, they had not implemented it at the time of inspection, and the associated risks remained.

However, the service had made some improvements since the last inspection. Leaders had reviewed and reduced the range of medicines held as stock without negatively impacting patient care. Staff followed processes for the secure storage of medicines, including controlled drugs and medical gases.

The service had improved the labelling of over-labelled medicines packs and ensured appropriate patient group directions (PGDs) were available. We saw that staff had addressed previous concerns regarding the quality of these packs, and they were now labelled appropriately.

The service also introduced processes to manage discharge medicines effectively. Staff dispensed medicines through pharmacy or ward-based systems, and they monitored uncollected medicines and contacted people to arrange collection where necessary.

Leaders told us they had appointed a pharmacist to support maternity services at this location and at St Richard’s Hospital. This showed progress in strengthening medicines governance, although the role was not fully embedded at the time of this assessment.

Whilst the service had taken some action to address previous concerns, it had not yet embedded consistent medicines management practices. This meant leaders could not demonstrate full assurance that medicines were managed safely across all areas.