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Bedford Hospital

Provider Bedfordshire Hospitals NHS Foundation Trust Type NHS Healthcare Organisation Region East

Overall rating: Not Yet Rated  View full CQC report

Domain ratings

Five CQC key questions
Safe
Not Yet Rated
Effective
Not Yet Rated
Caring
Not Yet Rated
Responsive
Not Yet Rated
Well-led
Not Yet Rated

Current CQC assessment

Single Assessment Framework

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

Not Yet Rated Assessed 23 January 2026
Date of assessment: 10-11 June and 15 July 2025. Bedfordshire Hospitals NHS Foundation Trust is a large general hospital across two sites, Luton and Dunstable University 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, which we rated as …

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 the 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 regulation in relation to staffing 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 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 7 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)
⚠ The triage area could not always support the number of women who arrived. Due to space constraints within triage and lack of an awaiting area, women who were awaiting review had to wait outside of triage near the entrance to the delivery suite and sometimes outside of the delivery suite …
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)
⚠ Staff did not always feel respected, supported and valued. The service did not manage cultural issues raised by staff effectively. Midwives reported incidents of racism that had occurred towards the internationally recruited cohort of staff, alongside more subtle microaggressions that reflected racial stereotypes and a lack of cultural awareness.
Must-do action 4 of 11
Must do
Well-led
The service must ensure incidents are managed appropriately.
Regulation: Regulation 17 (2)(b)
⚠ Serious incidents were not always reviewed in a timely manner and lessons were not always learned and embedded from serious incidents and external investigation when there were poor outcomes for women and birthing people, to reduce reoccurrence.
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 with the right qualifications, skills, training and experience to keep women safe from avoidable harm and to provide the right care and treatment. Managers did not accurately review and adjust staffing levels. The hospital was at capacity and staffing …
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. Staff were not always completing training in line with the Trust target of 90%.
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. There were also missing ECG checks for 6 days within a month. Of 309 items of …
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)
⚠ Staff did not always feel respected, supported and valued. The service did not effectively manage cultural issues raised by staff. Not all staff felt respected, supported and valued at a local level. Some staff did not feel safe to report concerns without fear of reprisal.
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. Staff were concerned that incidents of racism they reported to the trust would not be investigated in line with the trust’s values.
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)
⚠ Due to high acuity on the wards and the training of internationally recruited midwives amidst these staffing shortages, it was not always possible for staff to be supported in their learning, further adding to the strain of these working relationships and putting further pressure on this cohort of staff. Staff …
Must-do action 11 of 11
Must do
Safe
The trust must ensure that clinical waste is stored securely.
⚠ Staff did not always dispose clinical waste safely. 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 secure and on inspection there were clinical waste in …

Should-do actions (7)

Recommended improvements to enhance service quality.

Should-do action 1 of 7
Should do
Responsive
The service should ensure the maternity triage area is suitable to meet the service’s needs.
Should-do action 2 of 7
Should do
Effective
The service should ensure that junior midwives are able to get appropriate experience in all clinical areas.
Should-do action 3 of 7
Should do
Safe
The service should ensure that safety huddles are structured and confidential.
Should-do action 4 of 7
Should do
Safe
The service should ensure medicines are managed and stored appropriately.
Should-do action 5 of 7
Should do
Safe
The service should ensure all women’s risk assessments are completed and recorded at each contact.
Should-do action 6 of 7
Should do
Well-led
The trust should ensure that incidents are reviewed in a timely manner to ensure that themes and trends are identified
Should-do action 7 of 7
Should do
Well-led
The service should improve on triage processes and monitoring through audit.

Location details

CQC ID: RC9X5
Local authority: Bedford
Region: East

Inspection report

Type: Location
Date: 5 July 2024
Rating: Requires improvement
Actions: 11 must-do 7 should-do
AI-extracted 2 Jun 2026

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