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Leighton Hospital

Type NHS Healthcare Organisation Region North West Last inspected 22 Apr 2024

Overall rating: Requires Improvement  View full CQC report

Domain ratings

Five CQC key questions
Safe
Requires Improvement
Effective
Good
Caring
Good
Responsive
Good
Well-led
Requires Improvement

Earlier inspection findings

pre-2024 framework · 8 must-do 5 should-do

Must-do actions (8)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 8
Must do
Safe
The service must ensure that all staff are up to date with maternity mandatory training modules, safeguarding training and regular ‘skills and drills’ training.
Regulation: Regulation 12 (1)(2)(c)
⚠ Not all staff had completed mandatory training, including safeguarding and multi-professional simulated obstetric emergency training (PROMPT). Managers did not always ensure staff completed and updated their training.
Must-do action 2 of 8
Must do
Safe
The service must ensure there are enough staff with the right skills, qualifications, competencies, and experience to provide safe care and treatment for women, birthing people, and their babies. This includes staffing of maternity theatres and the maternity theatres recovery area in line with national guidance.
Regulation: Regulation 18 (1)
⚠ Staffing levels did not always match planned numbers, and planned numbers were not always adequate, putting the safety of women and birthing people and babies at risk. Medical staff numbers were insufficient, and midwives were undertaking roles (theatre recovery, scrubbing) not in line with national guidance.
Must-do action 3 of 8
Must do
Well-led
The service must ensure that incidents are graded in accordance with the Health and Social Care Act Regulation 20 Duty of Candour level of harm criteria to make sure people receive follow up care following an incident.
Regulation: Regulation 20 (1)(7)(a)(b)
⚠ Leaders graded harm or injury based on clinical outcome rather than impact on the person, leading to incidents being classified as no or low harm. This meant not all cases eligible for duty of candour were completed.
Must-do action 4 of 8
Must do
Well-led
The service must ensure incidents are investigated and reported in a timely manner.
Regulation: Regulation 17 (1)(a)(b)
⚠ The service did not always manage safety incidents well; staff did not always report them (e.g., 32% of significant PPHs were not reported). Managers did not always investigate incidents and share lessons learned in a timely way, with many incidents open for over 60 days.
Must-do action 5 of 8
Must do
Safe
The service must ensure it implements a standard operating procedure for timely second emergency theatre provision at all times so that staff follow a reliable and standardised process to ensure compliance with the emergency caesarean response times to ensure women and birthing people and their babies are not exposed to risk of harm.
Regulation: Regulation 12, 17 (1)(a)(b)
⚠ Response times for emergency caesarean sections were not always met, often due to theatre or staff unavailability for concurrent emergencies. The service had not produced a standard operating procedure for opening a second theatre, despite this being a repeating theme in incidents.
Must-do action 6 of 8
Must do
Safe
The service must ensure staff complete daily checks of emergency equipment.
Regulation: Regulation 12 (1)(2)(a)(d)
⚠ Staff did not always conduct daily safety checks of specialist emergency equipment, including resuscitaires and the neonatal emergency trolley. Some out-of-date equipment was found on triage.
Must-do action 7 of 8
Must do
Safe
The service must ensure medical staffing is reviewed so there are sufficient numbers of suitably qualified, competent staff to deliver the service in line with national guidance.
Regulation: Regulation 18 (1)
⚠ The service did not always have enough suitably qualified and competent medical staff, leading to delays in medical reviews and staff unavailability for concurrent emergencies. On the day of inspection, there was no SHO doctor cover for the evening shift.
Must-do action 8 of 8
Must do
Well-led
The service must ensure it operates effective governance systems and processes in order to monitor risk and performance in key safety metrics and to collect accurate and reliable data to enable oversight of this.
Regulation: Regulation 17 (2)(a)(b)
⚠ Leaders did not always operate effective governance processes, including under-reporting incidents to the national system and not including key safety metrics in board reports. Risks were not consistently identified or escalated, and data collected was not always reliable or correctly analysed.

Should-do actions (5)

Recommended improvements to enhance service quality.

Should-do action 1 of 5
Should do
Safe
The service should ensure it continues to monitor staff compliance with completing and escalating baby early warning scores so that all babies are risk categorised at birth.
Should-do action 2 of 5
Should do
Safe
The service should ensure that it implements a standard operating guideline for managing the telephone triage service in line with the most recent national guidance.
Should-do action 3 of 5
Should do
Well-led
The trust should ensure that plans to develop and implement a new maternity digital patient record are completed as a priority so that the service can monitor outcomes for women and birthing people.
Should-do action 4 of 5
Should do
Well-led
The service should consider capturing ethnicity data on all incident reviews and investigations to have full oversight of the care and treatment to ensure equality of access to care.
Should-do action 5 of 5
Should do
Safe
The service should ensure oxygen cylinders are stored securely in line with national guidance.

Location details

CQC ID: RBT20
Local authority: Cheshire East
Region: North West

Inspection report

Type: Location
Date: 22 April 2024
Rating: Requires improvement
Actions: 8 must-do 5 should-do
AI-extracted 3 Jun 2026

Related PFD reports

2022-0085 — Remi Koduah (Mar 2022)
2016-0449 — Charles Woodward (Dec 2016)