CQC rates Surrey maternity service inadequate

Published: 30 March 2023 Page last updated: 30 March 2023

The Care Quality Commission (CQC) has rated the maternity service at St Peter’s Hospital, run by Ashford and St Peter’s NHS Foundation Trust, as inadequate following an inspection in January. This is the first standalone inspection the maternity service has had, which previously also included a gynaecology service.

The inspection was carried out as part of CQC’s national maternity services inspection programme. This programme aims to provide an up-to-date view of the quality of hospital maternity care across the country, and a better understanding of what is working well, to support learning and improvement locally and nationally.

At this first inspection of maternity services, without gynaecology, CQC also rated how safe the service was as inadequate, and how well-led as requires improvement. How effective, caring and responsive the service is, are unrated, because CQC didn’t look at these three domains at this inspection.

Following the inspection, CQC served Ashford and St Peter’s NHS Foundation Trust, which runs the hospital, a warning notice. This means the trust must take urgent action to ensure women and babies in its care are not exposed to risk of harm in the service.

CQC’s rating of Ashford and St Peter’s NHS Foundation Trust remains good following this inspection.

Similarly, CQC’s rating of St Peter’s Hospital remains requires improvement.

Amy Jupp, CQC deputy director of operations in the south of England, said:

“It’s concerning that the quality and safety of maternity care at St Peter’s Hospital has deteriorated since our last inspection.

“Risk wasn’t always well managed in the service. This included in the service’s triage, where staff didn’t always have enough time to appropriately assess and action risks faced by women or to maintain accurate care records

“A factor behind this was the difficulty the service had in recruiting and retaining staff. While this is a problem affecting much of the NHS, leaders must find ways to ensure people’s care isn’t compromised by these staffing challenges.

“Part of the solution to improving the safety of people using the service must be addressing gaps in staff training and using safety incidents to drive learning. But the trust’s senior leaders must also improve their oversight of the service and set the right priorities to help it respond to the challenges it faces. 

“However, despite the pressure they faced, staff worked hard and collaborated well for women and babies using the service. They also understood how to protect people from abuse, and they managed medicines safely.  

“We also found the service engaged well with women and the community to plan and manage its care, and staff were committed to driving improvement. 

“Following the inspection, we told the trust’s senior leaders where they must make improvements and where there’s good practice on which they can build.  

“We continue to monitor the service and the wider trust, including through future inspections, to support it to deliver safe and effective patient care.” 

The inspection found: 

  • Some medical staff had not completed some mandatory training
  • There were significant issues with risk assessments, especially in triage. Staff did not have enough time to appropriately risk assess women, act upon identified risk within safe time frames or maintain accurate care records
  • The trust had recognised people’s privacy and dignity were compromised by the location of maternity-planned elective theatres
  • There were gaps in the service’s infection prevention control measures
  • There were significant staffing shortages that reflected national shortfalls. Staffing levels did not always match planned numbers, which put the safety of women and babies at risk. The service had issues with sickness, recruitment and retention of staff
  • Safety incidents were not always progressed within national time frames. Governance and risk processes required significant improvement because of a backlog of open enquiries – which caused delays and inconsistency in identifying themes, trends and shared learning for staff
  • Maternity leaders faced substantial challenges because of the trust’s opposing priorities, which caused missed opportunities to drive required improvements in the service. Trust leaders did not always respond swiftly to challenges within maternity, which meant services did not always perform well
  • Managers did not always have enough time to monitor the effectiveness of the service or utilise reliable information systems. They also did not have time to support staff to develop their skills to ensure they were competent.


  • All clinical staff received emergency skills and drills training, and midwives had completed key skills training specific to them
  • Staff collaborated well for the benefit of women, and they understood how to protect women from abuse
  • Staff managed medicines well
  • There was a positive transparent culture
  • Staff worked hard, despite workforce challenges, and they felt valued and included in plans to improve services. They were sympathetic to the needs of women receiving care. Staff understood the service’s vision and values, and how to apply them in their work
  • The service engaged well with women and the community to plan and manage services. Staff were committed to continually improving services.  

Contact information

For enquiries about this press release, email regional.comms@cqc.org.uk.

About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.