CQC tells Oxford University Hospitals NHS Foundation Trust to make improvements in maternity services

Published: 8 March 2024 Page last updated: 8 March 2024

The Care Quality Commission (CQC) has rated maternity services at Horton General Hospital as requires improvement, following an inspection in October.

Maternity services at Horton General Hospital in Banbury are run by Oxford University Hospitals NHS Foundation Trust and were inspected as part of CQC’s national maternity services inspection programme. The 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.

The overall rating for maternity services at Horton General Hospital is requires improvement. They have also been rated as requires improvement for how safe and well-led they are. The inspection didn’t rate how effective, caring, and responsive the service was.

This is the first time maternity services at Horton General Hospital have been rated as a standalone core service. Previously, maternity and gynaecology services were inspected and rated together.

Following the inspection, the ratings for Horton General Hospital have also changed. The overall rating for the hospital has been downgraded from good to requires improvement, as have the areas of safe and well-led.

The overall rating for Oxford University Hospitals NHS Foundation Trust remains as requires improvement.

Carolyn Jenkinson, CQC’s deputy director of secondary and specialist care said:

“When we inspected maternity services at Horton General Hospital we found a service with poor governance and ineffective systems and processes which meant women, people using the service and their babies could be put at risk of harm.

“We found examples of poor record-keeping, and people using the service weren’t always being risk assessed. The midwife-led unit used a national tool to assess whether someone giving birth was at risk of deteriorating, but staff weren’t always completing these records and leaders didn’t audit them. This lack of oversight meant leaders weren’t always able to identify issues or make improvements when issues were found.

“It was also concerning that safety equipment wasn’t always checked regularly, which meant some out-of-date equipment and products might be used on people. We found a blood giving set which had expired several months before the inspection, and an ambulance transfer bag with expired items inside. This could put women, people using the service and their babies at risk of harm.

“Staff weren’t always recognising and reporting incidents and near misses when they should have been. Incidents which should have been reported included when people gave birth at the midwife-led unit when they had planned to give birth at the hospital with consultants looking after them. These incidents could have been escalated so that staff can learn lessons for the future.

“We’ll be monitoring the trust closely, including through future inspections, to make sure women, people using the services and their babies are safe.”

Inspectors found:

  • The service wasn’t always following the best practice guidance by ensuring a second midwife was available to support during later stages of labour and birth
  • Although staff had access to policies and procedures, some policies were hard to follow and hadn’t been updated to reflect changes in other policies. This meant some women and people might not be directed to the right place to manage issues
  • Medicines were prescribed correctly and stored securely, but they weren’t always kept at the right temperatures. Some medicine cupboards were in a corridor where the temperature wasn’t monitored, and when fridges were not the correct temperature there was no evidence of action the service had taken
  • Staff didn’t always follow the trust’s policy to clean the birthing pool and ensure it was decontaminated correctly after use. However, the trust was taking steps to address this.


  • The service engaged well with the local community and had several ongoing projects to tackle health inequalities. They ran an outpatient clinic for refugees and asylum seekers at hotels in the local area, providing snack boxes for people and their children as they were often hungry during appointments, and planned clinic times around mealtimes so they didn’t miss out on a meal
  • The service had an open culture and staff worked well together as a team and were focused on the needs of women and people using the service.

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.