New Cross 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

Staff were positive about the learning culture of the service; they told us they received feedback from managers on incidents. The department had processes in place for shared learning. Reviews took place into care provided and learning was identified; there was a maternity dashboard in place. Staff were knowledgeable about the challenges at the service. Weekly risk meetings took place where leaders reviewed all term admissions to the neonatal unit and audited the care provided. Processes were in place around safeguarding, staff spoke positively about the safeguarding team and felt they could call them to provide any support. Staff completed safeguarding training. Staff were aware of escalation pathways and reasons for seeking escalation. During the on-site assessment, we found risk assessments were consistently completed and that risk factors were recorded. There were regular reviews of clinical risk. The environment was visibly clean and tidy and infection prevention control audits took place. Medicines storage areas were locked and secure and medicines were well organised. From January to September 2024 there was 100% compliance with 1 to 1 care in labour. However, there were high numbers of red flags in relation to delayed or time critical activity. We observed delivery suite staffing was below the recommended numbers on both days of the assessment. We found that following an accessibility drill in May 2024 when a member of staff went unchallenged, no further drills had taken place. Staff told us how it was sometimes difficult to get a medical review in triage as the named doctor was shared with the foetal assessment unit. Midwife staffing levels were up to funded establishment; however short staffing sometimes occurred at short notice. There were concerns by staff about sonography staffing levels, with not enough staff to perform the scans required, so agency sonographers were used.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The hospital sought feedback on people’s experience. For example, a patient perspective maternity survey improvement plan was in place using 2023 data results. The trusts results were about the same as other trusts for 54 questions. 281 patients responded to the survey; the response rate was 41%. An action plan was in place for questions that had deteriorated in comparison to 2022 and those questions that scored in the bottom 20% of the trusts nationally. Examples where improvement was identified included “before you were induced were you given appropriate information and advice on the risk associated with labour and during labour and birth” and “were you able to get a member of staff to help you when you needed it”. The trust identified themes and trends from complaints, for example in the September 2024 complaints report it was identified there had been an increased in complaints around clinical treatment from Obstetricians.

Staff responded positively about the learning culture. One staff member said doctors in particular were very proactive about sharing learning points with staff and they were well received. For example, an email was sent out sharing a poster and clinical advice on the treatment of diabetic ketoacidosis as there had been occurrences of the condition. Staff spoke about ‘Nudge of the Month’ with topics such as incidents and the trust policy on the topic was reshared. Staff gave examples of when they would submit an incident, and told us that when they reported incidents, they generally got updates and feedback from managers. However, more than 1 staff member felt the form was too long. Results from the latest staff survey showed that staff in women's and neonatal services rated ‘We are always learning’ 5.22 out of 10, slightly below the organisational average.

The department had processes in place for shared learning. There were infographics which including reminders to all staff such as “were they querying a urinary tract infection” and “were they reviewing antenatal women at 28 weeks' gestation?”. Action plans were in place following Maternity and Newborn Safety Investigation programme (MNSI) reports. Leaders completed midwifery led safety briefs where staff had an opportunity to highlight safety issues to help prevent harm and improve patient safety, such as ensuring blood glucose monitoring. There was a thematic review of maternity venous thromboembolism incidents between April and June 2024. The review identified areas of improvement such as anti-embolism stockings and language barriers. It also identified areas to improve such as discharging patients with a full course of thromboprophylaxis and providing practical demonstrations to patients using the artificial model and syringe. The Maternity services trust board report (July 2024) showed 100% of perinatal deaths continued to be reported, reviewed and monitored in line with the National Perinatal Mortality Review Tool. A thematic review by MNSI into all the investigations conducted by the trust revealed no major themes for the service. The trust had a local maternity dashboard that identified any areas needing attention and for reporting to board. For example, a review of the dashboard indicated booking dates remained in the higher tolerance levels for Q4 2023/24 and Q2 2024/25. The obstetric care meeting minutes September 2024 recognised tools for mortality reviews were not being completed in a standardised way. We reviewed letters where the trust had completed Duty of Candour and saw evidence that investigation reports had been shared and of lessons learnt; when required the trust apologised. Trends were also monitored and included delay in assessment on triage due to high acuity and women and birthing people who did not attend being followed up on discharge.

Women and birthing people spoke positively about the systems and pathways in the service. Those awaiting antenatal appointments agreed the booking process was good. Most women we spoke with received their required ultrasound scans on time. One woman who had been admitted for induction of labour said the service had been “fantastic from day 1”, had guided them throughout their pregnancy journey and staff had communicated well with them and their GP. Another said their pathway had been smooth, although the new mobile app was a change they needed to get used to, as they had previously received communications by letter. Feedback about triage was also positive, with women feeling they were both quickly and thoroughly assessed.

One doctor explained the booking process for the induction of labour pathway had recently changed and was all electronic. They told us inductions were limited to 5 a day, and that the consultant on call would prioritise the list. They said most of the time they had no problems getting the required women and birthing people in to be induced.

One staff member on delivery suite told us there were sometimes delays in women and birthing people arriving from other areas of the service due a lack of available staff to bring them. There were seperate anasthetic and theatre teams for caesarean section lists. However, a doctor said theatres were not always efficient, and turnover of women and birthing people could be quicker. Staff told us as a tertiary centre they accepted women and birthing people referred from outside of the trust. They told us the electronic records system they used was common in the local midwifery and neonatal system (LMNS) which allowed staff to easily access the records of women and birthing people being transitioned into the service. Staff told us that the system to transfer ultrasound reports to the electronic record system went down on occasions. However, leaders told us there was an option to print the report if required, so patient care was not affected. Once the system resumed, any reports that did not transfer at the time transferred over.

Partners provided us with some positive feedback; they said they had undertaken a lot of improvements to triage since the last CQC assessment. They also spoke of how the service would respond to outliers in performance data and provided responses and submissions to address them. They told us they were confident the trust would act when areas of concern were identified. Partners described transfers of care from the community and back as “seamless”. Partners spoke of the trust having high standards regarding national guidance, and as a regional level 3 unit, having strong pathways for transfer to the Neonatal Unit, and receiving women from outside of the trust. The self-referral process was described as “very quick” as women and birthing people no longer needed to go through their GP. Partners described good work around multiple births and Equality, Diversity, and Inclusion. Partners said the patient safety incident reporting framework was working well. However, a partner said they got mixed feedback regarding postnatal care. Issues included birth partners wanting more time with women and birthing people after birth, especially after a caesarean section when more support was needed. Partners also said there was a diverse local population, and there had been some issues with women who did not speak English as their first language being told they did not need an interpreter. Feedback also suggested improvement could be made around the reading of notes, and women explaining several times to various people about the same thing. Partners described issues around scanning capacity as a “whole system issue”, although recognised individual service issues, and noted divergence had been registered with the relevant bodies. They said the trust had done better than anticipated in getting staff through the required training.

As part of the weekly risk meeting, leaders reviewed all term admissions to the neonatal unit and audited the care provided. We reviewed the department’s audit of delays in care specifically related to induction of labour August to October 2024 and noted that out of the 30 cases discussed at the weekly risk meeting there were no instances in which delays during the induction of labour process were linked to admissions to the neonatal unit or any adverse outcomes relating to those delays. We reviewed the maternity dashboard September 2024 and noted from January to September 2024 there was 100% compliance with 1 to 1 care in labour. The dashboard was colour coded red, amber and green. Areas mainly rated as green included bookings before 10 weeks, 3rd and 4th degree tears, eclampsia and breastfeeding initiated. Areas coded as red included induction of labour rate, percentage of births on the midwife led unit and number of bookings. Activity overall in maternity remained high and looked to remain high due to the maintained increase in booking numbers. The intrapartum matron report dated August 2024 reported on the percentage of women triaged within 15 minutes between January 2024 and September 2024 and found that on average 81% of women were seen within 15 minutes. In relation to Red Flags Birthrate Plus Acuity Tool, there were 41 red flags in July 2024, this showed a significant increase in month as previous months had been less than 20 flags. The department had broken these down and found the increase appeared to have been around delays and cancellations with 34 occasions recorded as delayed or cancelled time critical activity. In September 2024 there was 42 instances of delayed or cancelled time critical activity and 65 in October 2024. The directorate had experienced significant disruption to patient flow with reduced capacity on the antenatal and postnatal bed base due to building works.

Women and birthing people we spoke with said they felt safe in hospital, with one woman stating she felt she could tell the staff anything, and another saying staff had asked her how she was feeling about going home. Women were able to give examples of how staff had kept them safe. However, some women said they weren’t sure where to raise concerns about staff if they had any.

Staff said they received a 3-hour safeguarding update during an annual study day, where real case studies were used. We heard that a new initiative had been put in place where a situation, background, assessment and recommendation handover automatically appeared on the electronic record system where a woman or birthing person had a child protection plan in place. Leaders told us they were always made aware when a women or birthing person with safeguarding concerns were going to be transferred to their area of work. Staff were made aware of safeguarding concerns during shift handovers. One midwife told us that when there were domestic safeguarding concerns, staff carried out parenting assessments more frequently. A staff member in antenatal clinic told us how they always asked women and birthing people if they could be seen alone for a part of the antenatal check-up and when having vaccines so they could complete routine enquires on domestic abuse. They also told us they had moved the weighing scales to another room to accommodate privacy to ask these questions. Staff spoke positively about the trust safeguarding team and felt they were able to call on them for support.

There was a routine question for domestic abuse built into the trusts electronic system, this was mandatory and needed to be completed at every contact. However, we heard there was an option to say unable to ask that did not require a rationale. A recent matron's report highlighted learning following an accessibility drill carried out in May 2024. As part of the drill an unfamiliar member of staff in uniform was asked to gain access to the maternity unit and walk around, attempting to access different areas. The member of staff was able to tailgate a member of the public and access an inpatient area where they were unchallenged, gained access to an inpatient area, bays, side rooms and visualised patient identifiable data. Staff identified actions to prevent this happening again, however, no further drills had taken place since. Furthermore, staff identified that doors did not always lock down correctly when triggered by a baby tag. Mitigations were in place including a staff escort for every baby being discharged, and 24-hour security at maternity reception until a permanent solution was in place. This was on the risk register. Staff received safeguarding training for children and adults; compliance rates for September 2024 varied between 84% and 97%. The department recorded details around safeguarding incidents, operational safeguarding activity and risks linked to safeguarding. Data included information such as how many unborn children were on child protection plans; early support plans and how many strategy meetings had been attended. The department monitored compliance with safeguarding supervision; records from April 2024 to March 2025 showed 98% of midwives were compliant with safeguarding supervision. Various policies and guidelines were in place around safeguarding children and adults.

Women and birthing people said staff explained any risks of procedures, and any risk factors in their pregnancy so that they were well informed. Results from the 2024 CQC Maternity Survey showed women and birthing people rated advice on risks of induction and advice on benefits of induction ‘about the same’ as service users of other trusts.

Staff were aware of escalation pathways and of the reasons for seeking escalation. We saw ‘red’ and ‘amber’ flags displayed in triage, and staff could explain the escalation process for both clinical and staffing flags. A staff member on delivery suite said that the use of the Birthrate Plus acuity tool was “a part of everyday practice” and if there had been an emergency, it would be retrospectively completed. Staff on antenatal ward could explain how they used the 4 acuity categories that had been in place for 2 weeks at the time of assessment. There was a named doctor allocated to triage between the hours of 1-9pm, however they were shared with the foetal assessment unit, and staff reflected it was sometimes difficult to get a medical review. Leaders felt their team were good at escalating concerns, and that they were taken seriously. A midwife on antenatal ward told us they could usually get support from a doctor at night when needed, and the delivery suite co-ordinator could help to track them down if they were not immediately available. Staff told us that the success of escalation was dependent on who you dealt with and commented the same was true when speaking to the manager on-call.

During the on-site assessment we found that risk assessments were consistently completed at every contact, and there was appropriate escalation/onward referral where required. Risk factors such as increased body mass index, increased age and ethnicity were recorded. Carbon monoxide levels were consistently monitored and recorded. Mental health risk assessments and routine enquiries regarding domestic abuse were also consistently recorded. We saw that RAG (red, amber, green) risk ratings were also consistently documented in triage records, although in 1 case, the RAG rating had been incorrectly calculated for a woman presenting with reduced foetal movements. Foetal growth was consistently documented on personalised growth charts and questions about foetal movements were consistently documented from 25 weeks of gestation onwards. Fresh eyes were routinely completed where cardiotocography had been performed. Risk awareness training compliance was 93.3% and risk management training was 75%. There were regular reviews of clinical risk such as patient safety incidents, red flags, maternity triage and WHO safety checklist compliance which we saw were reported on in various reports such as the perinatal integrated quality and safety governance report, the quality improvement divisional summary and the intrapartum matrons report.

Feedback from women and birthing people regarding the environment and equipment was largely positive. Most women stated the environment was visibly clean, and they told us they saw domestic staff cleaning wards daily. One woman said that the domestic staff offered to change her bedsheets every day. However, a woman who had had a caesarean section said that her baby had been put in bed with her for several hours after her surgery while she was still drowsy as there were not enough cots available. She felt that this was not safe. This was raised with staff on the day of the inspection. We saw that this had been reported as an incident, and 5 additional cots were ordered by staff.

Staff told us they generally had the equipment they needed to do their jobs. Some staff highlighted how they could benefit from more tablets or computers to complete patient documentation. A staff member in transitional care told us cots were sometimes in short supply, but they could generally source one quickly from the neonatal ward. Leaders reflected that the service was in an aged building, in need of modernisation and was small for the volume of people using the service. However, they also spoke about the improvements to the environment they had planned for their department. This included purchasing different coloured chairs for women and birthing people who were fasting to help with quick identification in case of deterioration and installing a television to allow a health promotion information loop to be displayed in clinic. They had also purchased a hot drinks machine for service users in response to feedback.

The environment was secure, with swipe card access to all ward areas. We noted there were key safes outside of doors for security as doors automatically locked when fire alarms were triggered. Theatres were located at one end of delivery suite, and there was sufficient space to push a bed through the ward to theatre in case of an emergency. We checked emergency trolleys, resuscitaires and other emergency equipment as part of the assessment and were assured that they were consistently checked daily as per trust process. We checked samples of consumable items from emergency trolleys and found they were all in date with sterile packaging intact. We viewed a sample of medical devices including cardiotocography machines, tympanic thermometers and patient monitors and found them to be within their service dates. We checked a sample of medical air ports and found they had removable caps. We noted that a Control of Substances Hazardous to Health cupboard containing cleaning products had been left unlocked and the fire door to the room it was in had been wedged open. We raised both issues to staff who rectified them immediately.

The trust provided staff with pool evacuation training and refresher training. We saw certificates of analysis that showed pool room and drinking water passed the requirements dated October 2024. The environmental audit result summary for the delivery suite dated September 2024 showed it fell slightly below the target score of 98.00% scoring 97.49%. Dust was listed as a main reason for the failings in 9 areas. The audit results summary for antenatal in July 2024 showed it passed the departments target score of 85%. The maternity ward also passed the target score of 95% in September 2024. However, the fire service had provided the hospital with an enforcement notice following a visit to the premises in July 2024. The outcome of the visit was that the hospital had failed to comply with fire safety because people were unsafe in case of a fire. The fire risk assessments seen at the time by the fire service were found to not be suitable or sufficient, lacking detail and failing to identify many of the serious deficiencies identified. As a result, the trust had completed an action plan with expected completion dates.

Women and birthing people felt there were enough staff, and that they were friendly and helpful. They commented that call bells were answered promptly. Results from the 2024 CQC Maternity Survey showed women and birthing people rated confidence and trust in staff, attention from staff during labour, and attention from staff after birth ‘about the same’ as service users of others trusts. Clear communication of staff was rated ‘somewhat better than expected’, with a rating of 9.5 out of 10.

Leaders told us midwifery staffing levels were up to funded establishment in the service, however short staffing sometimes occurred at short notice due to sickness. They also said they did not use agency midwives, and that bank shifts were covered by substantive staff. Fifteen newly qualified midwives were due to join the service shortly, and student midwives who trained in the service generally wanted to stay. Leaders told us how their Birthrate Plus was due to be reassessed later in 2024 or early 2025. Leaders were concerned about sonography staffing levels at the time of the assessment. They told us there were not enough trained staff to perform the scans required and that agency sonographers were being used. However, they told us they had been working in partnership with radiology colleagues and that they also had new midwife sonographers training at another local hospital. Feedback from staff was mixed. Some staff felt areas were understaffed and how staff were often redeployed to work in other parts of the service. Leaders felt redeployments were affecting staff resilience. A doctor we spoke with said they felt there were shortages of midwives and physician assistant grades. Other staff members felt staffing levels were good. Staff told us that band 7 midwives took a significant amount of bank shifts in the past, but due to trust wide changes in policy which meant they were paid at a band 6 rate, take-up had reduced.

We observed delivery suite staffing was below the recommended numbers. For example, on day 1 there were 6 midwives on shift in the morning and 7 in the afternoon out of the recommended 9. On day 2, there were 7 midwives on shift during the day out of the recommended 9, although the recommended 8 midwives were due to staff the night shift. On day 1, we observed that postnatal ward was a midwife short, and on day 2, we observed that foetal assessment unit was a midwife short. We observed a safety huddle where staffing levels as well as activity and capacity for the day were captured. Midwifery redeployments were decided here, with staff members’ experience and preferences taken into account. An infographic shared with us showed that in September 2024, 347.5 of staff’s working hours were redeployed to other parts of the service. The duty manager of the day also took the bleep at this huddle. Staff at the huddle told us that the duty manager of the day had been in place for around 18 months and was very successful because it meant they could deal with unforeseen incidents and free up clinical staff.

Midwifery staffing was at funded establishment although slightly below the rate recommended by the 2022 Birthrate plus assessment. Since the assessment, the deficit was recruited to. We reviewed midwifery staffing numbers for a 4-week period up to 31 October 2024. Shifts, of which there were 3 per day, were RAG (red, amber, green) rated depending on the severity of any shortages. Over this period there were 26 ‘red’ shifts on postnatal ward, 20 on delivery suite, 8 on induction unit, 6 in foetal medicine, and 3 on the midwifery led unit. In August, September and October 2024, 53%, 53% and 48% of shifts respectively on delivery suite, induction and triage had staffing that met acuity requirements. Guidance from the Royal College of Midwives suggests that services should aim to achieve positive acuity 85% of the time. There were 2 substantive obstetric and gynaecology consultant vacancies, which we were told had been recruited to after the on-site inspection. There were also 2 senior and 3 junior registrar vacancies, awaiting new starters in December 2024. Sickness levels for the 12 months prior to the assessment were 6.16% in women’s and neonatal services. Staff undertook a mandatory training package and compliance with most topics was above the trust target of 90%. However, compliance was significantly below target for manual handling, adult basic life support, and mental health level 2 at 77.1%, 72.3% and 75.5%, respectively. Staff attended Practical Obstetric Multi-Professional Training (PROMPT) days. Most staff groups were at or near target compliance, however compliance for the general anaesthetists on call was 61% as of October 2024. Compliance with foetal monitoring training was below target at 69% for obstetric registrars, increasing to 90% by December 2024. Midwives completed competency booklets specific to areas of work. For band 6 midwives, this was a self-assessment process. Staff underwent an annual appraisal, overall completion rates of which were 76.5%

Women and birthing people stated they saw and heard staff washing their hands and using alcohol gel before treating them. They also said staff used personal protective equipment when undertaking procedures such as examinations.

Staff did not have any concerns about infection prevention and control (IPC). They told us that they could call for support from the IPC team if, for example, they had a patient who needed to isolate.

The environment was visibly clean and tidy. Most staff were bare below the elbow as per trust policy, though we noted that 1 staff member was wearing a wristwatch. There were sufficient handwashing facilities and good access to stocks of personal protective equipment and alcohol gel. We saw that cleaning schedules were signed and up to date and some, but not all, equipment on wards had green ‘I am clean’ stickers on. Notices were in place to encourage visitors to wash their hands.

There were infection prevention and related policies available for staff. Leaders completed 5 moments in hand hygiene audits; the latest dated November 2024 had a compliance rate of 100%. Hand hygiene assessment mandatory training compliance was 82.7% and Infection prevention training compliance was 98.45%. We reviewed the intrapartum matrons report dated August 2024 and found the delivery suite, maternity triage unit and midwifery let unit had scored above 96% compliance in the infection prevention assure environment ward trend report in July and August 2024. There had been 4 positive MRSA neonatal screens discharged from the maternity ward D10 between 6 July 2024 and 20 July 2024, we found an action plan had been put into place in response to this.

Most women and birthing people said they received sufficient pain relief and choice. One woman said staff explained any risks and effects of medication. However, a woman who spoke limited English said she had been offered pain relief on the first day after giving birth but not after and so had requested pain relief on day 3; she felt that staff didn’t understand her and asked if it was for her baby. Another woman said she was refused gas and air in one area of the service by staff, but this was challenged by another staff member. In the 2024 CQC Maternity survey, respondents rated both pain management during labour and birth, and pain management after birth ‘about the same’ as service users of other trusts.

Staff told us there was an excellent clinical pharmacy presence to support staff on the wards with medicine optimisation. The pharmacy department supported staff with managing medicine processes such as ordering and receiving medicines. Staff told us they had access to relevant medicine policies, procedures and guidelines and good access to emergency medicines and critical medicines out of hours. Midwives told us they were able to supply and administer certain medicines using Patient Group Directions (PGD) specific to their professional role. We were shown two new PGDs that had been developed for maternity which ensured patients had access to medicines. A manager we spoke with said that they were hoping to have a ferrous sulphate (iron) PGD introduced soon.

We observed clinical checks being undertaken by clinical pharmacists, and doses were double-checked against electronic systems. Any discrepancies or medicine issues were resolved and recorded to ensure the effective continuation of treatment. Medicines for discharge were screened by clinical pharmacists and checked for accuracy. We observed the preparation of an intravenous antibiotic by 2 nurses. The double check process followed trust policy to ensure the correct medicine and dose was prepared. Medicines storage areas were locked and secure with access only to authorised staff. A pharmacy technician checked medicine storage areas every 2 weeks. Medicines were stored neatly and were well organised in all areas seen. We observed that there was no door to the medicine storage area on the triage unit. We were told that this had been on the risk register for some time, however medicines were stored securely within locked cupboards. Medicines used in medical emergencies such as for anaphylaxis and resuscitation were stored safely in tamper-evident trolleys which followed Resuscitation Council (UK) guidance. Oxygen cylinders were in date and ready to use. We observed that staff recorded safety checks to ensure the medicines were safe to use. Medicines, including Controlled Drugs, were stored securely and within their expiry date. Medicines requiring refrigeration were stored securely and temperature monitoring was recorded to ensure medicines were safe to use. Some medicine storage areas were very warm, and temperature records showed the room temperature was sometimes above the recommended storage for medicines. However, this was known to the trust and included on the risk register. A temperature monitoring policy was in place and if the ambient room temperatures went above the recommended safe level this was escalated to pharmacy and action was taken. Medicines shelf life and stock levels were continuously monitored to ensure the safety of the medicines.

We reviewed 5 medicines administration records. They were well documented with route and time of administration, including recording a reason if a medicine was not given. Where a ‘PRN’ (when required) medicine was administered, staff recorded why it was needed. The information we looked at showed people were receiving their medicines as prescribed. Processes were in place to ensure all wards and units had medicine stock checks which ensured there were enough medicines available. Pre-packs of commonly prescribed medicines ‘To take Out’ (TTO) were available which helped speed up the discharge process. A ‘Maternity Pre-Pack TTO Procedure’ was available for staff to follow. Patient weights were recorded to ensure the correct dose was prescribed. Venous thromboembolism (VTE) assessments were mandatory which followed the trust antenatal and postnatal thromboprophylaxis policy. VTE assessments had been completed on all records seen. Allergy status of patients was consistently recorded. Processes were in place for reviewing antibiotic prescribing, including documenting a reason for the antibiotic choice. A review date at 48-72 hours after initiation of treatment was highlighted on medicine charts. Controlled drugs (CDs) were stored safely and securely with access restricted to authorised staff. Checks were undertaken twice a day and recorded by 2 staff. Checks of CDs showed that they were within date and stock balances were accurate. CD audits were undertaken every quarter for all areas. Any action summaries were fed back to the areas and would be followed up in the next quarterly audit. There was a clear process in place for managing and reporting national patient safety alerts for medicines. Staff were able to talk through a recent patient safety alert and describe the action taken. Processes were in place for reporting medicine errors or incidents and a clinical pharmacist attended weekly governance meetings and discussed any incidents reported.