The Care Quality Commission (CQC) has again rated maternity services at both Bedford Hospital and Luton and Dunstable Hospital as inadequate, following focused inspections in June and July last year.
Both hospitals are run by Bedfordshire Hospitals NHS Foundation Trust.
These unannounced focused inspections were carried out to follow up on the progress of improvements CQC told them to make following their previous inspection. CQC found that only minimal improvements had been made, with the services remaining in breach of regulations around staffing and good management of the service, and were now also in breach of regulations relating to safe care and treatment.
As a result, in September, CQC placed conditions on their registration requiring them to outline how they were going to make rapid improvements to risk management, how they were effectively governing the service, and ensuring staff completed the necessary mandatory training requires to keep women and their babies safe.
They submitted an action plan that reassured CQC they were going to take immediate action.
As a result of this follow-up inspection, CQC has again rated maternity services at both hospitals as inadequate overall, as well as for how safe and well-led they were. Across both services CQC did not look at the following key questions and they keep their previous ratings, caring remains rated as good, responsive and effective remain requires improvement.
Carolyn Jenkinson, CQC deputy director of hospitals in the East of England, said:
“We were deeply concerned that improvements in maternity services were happening too slowly, with little change since our previous inspection. While we found caring staff, poor leadership meant both they and the women using the services were being let down.
“At this inspection, low staffing level was having the biggest impact on women’s experiences. Access to services was often delayed at both hospitals. The triage service was frequently understaffed, and at Bedford, our inspectors saw 451 calls out of 2,097 went unanswered or abandoned by the caller due to wait times, putting women at risk of not receiving the care they needed.
“Low staffing level also limited women’s choices. At Bedford Hospital, the elective caesarean service for women who were high risk and unable to labour was paused 32 times over a six-month period because there weren’t enough staff to support those who didn’t require emergency care. At Luton and Dunstable Hospital, women also experienced delays to elective caesarean sections as well as induction of labour. We also saw frequent diversions to other hospitals due to staffing shortages, which may lead to distress for women who had made specific plans at their chosen hospital.
“Staff at Luton and Dunstable told us low staffing levels were affecting staff morale and contributing to increased sickness absence, which in turn affected the safety of services. We were very concerned to hear that staff did not always feel safe at work.
“Leaders didn’t ensure staff completed mandatory training or risk assessments, and services were not learning effectively from incidents. Some incidents remained open for more than 60 days. At Luton and Dunstable Hospital, more than 1,500 incidents were open at the time of our inspection, with over 1,100 overdue for investigation or closure, increasing the risk of incidents being repeated.
“We have shared our findings with the trust and will continue to monitor these services closely, including through further inspections, to ensure improvements are delivered quickly and people are kept safe.”
Inspectors found at both hospitals:
- Staff didn’t always assess risks to people's health and safety or mitigate them where identified.
- There were significant backlogs of incidents awaiting investigation, and lessons were not consistently learned from incidents and complaints.
- Not all staff completed mandatory training, with particular concerns around medical staff completing safeguarding and emergency training.
- The service had many out-of-date policies and clinical guidelines, including those covering baby abduction, post-partum haemorrhage and sepsis management.
- The trust didn't comply with five of the ten safety actions in the clinical negligence scheme in 2024/25 for trusts maternity incentive scheme.
However:
- Women described staff as attentive and respectful of their privacy and dignity.
- Women were able to share their experiences and provide feedback through the local maternal and neonatal voices partnership, which also regularly feeds back to the trust.