Home / Sources / CQC / Airedale General Hospital
Index live
Source · CQC inspection

Airedale General Hospital

Type NHS Healthcare Organisation Region Yorkshire & Humberside Last inspected 26 May 2023

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 · 7 must-do 12 should-do

Must-do actions (7)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 7
Must do
Caring
The service must ensure care and treatment of service users is provided with the consent of the relevant person which is in line with national guidance.(Regulation11(1))
Regulation: Regulation 11 (Need for consent)
⚠ We reviewed consent forms used by clinicians in maternity services and found the consent forms did not always contain up to date information for all maternity procedures to meet national guidance. We also found consent forms that had been photocopied multiple times rendering some areas unreadable. For example, we reviewed …
Must-do action 2 of 7
Must do
Safe
The service must ensure clear systems are in place to prioritise and risk assess women, pregnant people and babies receiving care or treatment and do all that is reasonably practicable to mitigate any such risks.(Regulation12(2)(a)(b))
Regulation: Regulation 12 (Safe care and treatment)
⚠ The Maternity Assessment Centre had no clear system in place to prioritise and risk assess patients. The triage tool did not give target timescales for patients to be reviewed by medical staff. Staff told us there was no process or guidelines to prioritise women and pregnant people, they used their …
Must-do action 3 of 7
Must do
Safe
The service must ensure Cardiotocography (CTG) fresh eyes are completed in line with guidance to assess the risks to women, pregnant people and babies receiving care or treatment and do all that is reasonably practicable to mitigate any such risks.(Regulation12(2)(a)(b))
Regulation: Regulation 12 (Safe care and treatment)
⚠ Staff did not always use a ‘fresh eyes’ approach to review Cardiotocography (CTG). Overall compliance was 50% in July, 40% in August and 60% in September. Across all three months, fresh eyes compliance was in line with guidance 53% of the time. We reviewed governance meeting minutes for the last …
Must-do action 4 of 7
Must do
Safe
The service must ensure that safeguarding systems and processes are established and operated effectively to prevent abuse of service users.(Regulation13(2))
Regulation: Regulation 13 (Safeguarding service users from abuse and improper treatment)
⚠ We did not see evidence of safeguarding adults training in line with national guidelines. Not all staff accessed electronic systems to check identified safeguarding concerns, and safeguarding information was not always handed over. We observed safeguarding information had not been discussed or documented during handover on labour ward; staff told …
Must-do action 5 of 7
Must do
Well-led
The service must ensure systems embedded to assess, monitor, and improve the quality and safety of the services provided in the carrying on of the regulated activity.(Regulation17(2)(a)).
Regulation: Regulation 17 (Good governance)
⚠ Policies and documentation were not always kept up to date, and audits were not always completed in line with trust targets. Action plans were not always completed or updated in a timely way. There was a lack of oversight on issues such as appraisals, training compliance, monitoring risk assessments and …
Must-do action 6 of 7
Must do
Safe
The service must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed to meet the needs of people who use the service.(Regulation18(1)).
Regulation: Regulation 18 (Staffing)
⚠ The service did not always have enough nursing staff to care for women and keep them safe. The service did not have enough maternity staff with the right qualifications, skills, training, and experience to keep women safe from avoidable harm and to provide the right care and treatment. Staffing was …
Must-do action 7 of 7
Must do
Safe
The service must ensure staff receives such appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform.(Regulation18(2)(a)).
Regulation: Regulation 18 (Staffing)
⚠ The service provided mandatory training in key skills, but not all staff had completed it. The service was unable to evidence training figures, including levels of appropriate safeguarding adults training or competency checks in medicines management. Staff did not always receive regular appraisals. Staff were not up-to-date with their mandatory …

Should-do actions (12)

Recommended improvements to enhance service quality.

Should-do action 1 of 12
Should do
Safe
The service should enable timely access to evacuation nets for the birthing pools and this is monitored.
Should-do action 2 of 12
Should do
Well-led
The service should consider formalising systems to implement, monitor and embed quality improvements.
Should-do action 3 of 12
Should do
Safe
The service should review the use of carpets in waiting areas and evidence they are cleaned in line with infection prevention and control guidance.
Should-do action 4 of 12
Should do
Responsive
The service should continue to engage in the development of the maternity voices partnership and develop systems to gain insight and feedback from people who use the maternity service.
Should-do action 5 of 12
Should do
Well-led
The service should continue to improve governance and meeting structures and facilitate wider staff group attendance.
Should-do action 6 of 12
Should do
Safe
The service should ensure cleaning checklists are in place for all areas of maternity services.
Should-do action 7 of 12
Should do
Responsive
The service should ensure there are systems in place to actively engage with women who uses services.
Should-do action 8 of 12
Should do
Well-led
The service should work to enable maternity safety champion meetings to be held at a frequency in line with national guidelines.
Should-do action 9 of 12
Should do
Well-led
The service should ensure action plans evidence clear status and monitoring information to enable the service to monitor the timeliness and completion of actions.
Should-do action 10 of 12
Should do
Caring
The service should ensure showering facilities available to patients are suitable to provide privacy and dignity.
Should-do action 11 of 12
Should do
Safe
The service should embed systematic, structured handovers with clear roles and outcomes.
Should-do action 12 of 12
Should do
Well-led
The service should continue to develop systems and processes to ensure the risk register is up to date and accurately reflects the status of risks.

Location details

CQC ID: RCF22
Local authority: Bradford
Region: Yorkshire & Humberside

Inspection report

Type: Location
Date: 26 May 2023
Rating: Requires improvement
Actions: 7 must-do 12 should-do
AI-extracted 3 Jun 2026

Related PFD reports

2024-0658 — Alfie Hinton (Dec 2024)
None — Stanford Bell (Jul 2018)