Source · CQC inspection

Luton and Dunstable Hospital

Provider Bedfordshire Hospitals NHS Foundation Trust Type NHS Healthcare Organisation Region East Last inspected 23 Jan 2026

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

Current CQC assessment

Single Assessment Framework

From 2024 CQC rates services through ongoing assessments rather than comprehensive inspections.

Requires Improvement Assessed 23 January 2026

The service is not performing as well as it should and we have told the service how it must improve.

Date of assessment: 10-11 June and 15 July 2025. Bedfordshire Hospitals NHS Foundation Trust is a large general hospital that provides maternity services across two sites, Luton and Dunstable Hospital and Bedford Hospital. The Trust has approximately 1,100 overnight inpatient beds across the two sites and provides a comprehensive range of general medical and surgical services, including Emergency Department (ED) and maternity services for people in Luton, Bedfordshire, Hertfordshire, and parts of Buckinghamshire. This assessment looked at maternity services to follow up on the concerns identified at the previous assessment, …

Ratings by service

Maternity

Inadequate

May 2025

Regulatory breaches & enforcement

Current-framework "must do" equivalent

Breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, stated verbatim in the CQC assessment.

Urgent enforcement Overall

Following our follow-up visit on 15 July 2025, we imposed conditions under section 31 of the Health and Social Care Act 2008 on the registration of maternity services at Bedfordshire Hospitals NHS Foundation Trust.

· 23 Jan 2026 · CQC source

Warning notice Well-led

The service was previously in breach of legal regulations in relation to staffing, mandatory training, equipment, culture, clinical waste management and good governance and a section 29a warning notice was served.

Regulation: Regulation 17 (Good governance) · 23 Jan 2026 · CQC source

Breaches identified (1)

Breach Safe

At this assessment, the service remained in breach of some of these regulations along with a new breach in safe care and treatment.

Regulation: Regulation 12 (Safe care and treatment) · 23 Jan 2026

Earlier inspection findings

pre-2024 framework · 11 must-do 6 should-do

Must-do actions (11)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 11

Must do

Safe

The service must ensure the triage unit has enough staff to manage all the functions included safely.

Regulation: Regulation 18 (1)

⚠ We observed that triage was overburdened with too many functions for 1 midwife and 1 MCA to safely manage. The functions included assessing and prioritising women, escalating to the appropriate member of staff, and answering the telephone triage line.

Must-do action 2 of 11

Must do

Safe

The service must ensure that medical staff completion of training is in line with the trust target.

Regulation: Regulation 18 (2)(a)

⚠ Medical staff did not always keep up to date with their mandatory training. The overall compliance rate for both mandatory and advanced mandatory training was 87% which did not meet the trust target of 90%.

Must-do action 3 of 11

Must do

Well-led

The service must demonstrate its supports its staff by challenging unacceptable behaviours and language. This includes, but is not limited to, racism and discrimination.

Regulation: Regulation 18 (2)(a)

⚠ We spoke with members of staff who reported that there had been episodes of division and racism toward the internationally recruited midwives that was not always adequately addressed by the trust.

Must-do action 4 of 11

Must do

Safe

The service must ensure incidents are managed appropriately.

Regulation: Regulation 17 (2)(b)

⚠ Of the 198 incidents reported 47 were not graded which meant we could not be assured that they were being reviewed and investigated as required. Incidents rated ‘low harm’ in October 2022 were still open and awaiting final approval, which meant that incidents were not always managed in a timely …

Must-do action 5 of 11

Must do

Safe

The service must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced midwives to provide safe care and treatment across the service and reduce delays in provision of safe care to reduce the risk of harm for women, birthing people and babies.

Regulation: Regulation 18 (1)

⚠ The service did not always have enough nursing and midwifery staff to keep women and babies safe. On the first day of inspection 6th November 2023 the hospital was at capacity and staffing pressures had contributed toward the trust decision to go on divert.

Must-do action 6 of 11

Must do

Safe

The trust must ensure staff complete mandatory training in line with the Trust’s own target.

Regulation: Regulation 12(1)(2)(a)(c)

⚠ Not all staff had completed training in line with trust target.

Must-do action 7 of 11

Must do

Safe

The trust must ensure equipment is checked in line with Trust policy and documented clearly.

Regulation: Regulation 15(1)(2)(c)(d)(e)

⚠ Staff did not always carry out daily safety checks of specialist equipment. On the delivery suite resuscitation trolley checks were missing on 4 days out of 31 days in October 2023 without an explanation. Of 309 items of electrical equipment, 14 were overdue including 6 air/oxygen blenders, 1 CTG, 1 …

Must-do action 8 of 11

Must do

Well-led

The trust must ensure its supports all staff, including those with particular equality characteristics, to feel respected and valued and support an environment where staff are encouraged to speak up and raise concerns without fear of blame or reprisal.

Regulation: Regulation 18 (2)(a)

⚠ Not all staff felt respected, supported and valued at a local level. Staff did not feel able to report instances of racism when this had been experienced on the ward and between midwifery staff, including managers.

Must-do action 9 of 11

Must do

Well-led

The trust must demonstrate its supports its staff by challenging unacceptable behaviours and language. This includes, but is not limited to, racism.

Regulation: Regulation 18 (2)(a)

⚠ Staff did not feel able to report instances of racism when this had been experienced on the ward and between midwifery staff, including managers.

Must-do action 10 of 11

Must do

Well-led

The trust must ensure that internationally recruited staff receive appropriate and ongoing support to enable them to carry out the duties they are employed to perform.

Regulation: Regulation 18 (2)(a)

⚠ Staff that were responsible for the pastoral support for internationally recruited midwives were not clear on their future with in the trust as their seconded posts were due to end in December 2023.

Must-do action 11 of 11

Must do

Safe

The trust must ensure that clinical waste is stored securely.

⚠ Sharp bins were labelled correctly on the wards however the clinical waste was not always stored securely. Clinical waste was taken off the maternity unit and stored for collection. This storage area was near the entrance of the maternity unit and was accessible to the public. This area was not …