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James Paget Hospital

Provider James Paget University Hospitals NHS Foundation Trust Type NHS Healthcare Organisation Region East Last inspected 1 Apr 2026

Overall rating: Good  View full CQC report

Domain ratings

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

Current CQC assessment

Single Assessment Framework

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

Good Assessed 1 April 2026
The service is performing well and meeting our expectations.
Date of assessment: 16 September 2025. James Paget Hospital is part of James Paget University Hospitals NHS Foundation Trust and offer a range of hospital services to people living in north-east Norfolk and north Suffolk. This assessment looked at maternity services to follow up on the concerns identified at the previous inspection, which we rated as inadequate. The new maternity service rating has been combined with the ratings of the other services based on the most recent assessments and the rating for James Paget Hospital is now good. See our …

Ratings by service

Maternity
Requires Improvement
Apr 2025

Earlier inspection findings

pre-2024 framework · 10 must-do 7 should-do

Must-do actions (10)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 10
Must do
Safe
The service must ensure all staff complete mandatory training.
Regulation: Regulation 12 (Safe care and treatment)
⚠ The service provided mandatory training in key skills but did not always make sure all staff completed it. Midwifery staff did not always receive and keep up to date with their mandatory training. Medical staff did not always receive and keep up to date with their mandatory training.
Must-do action 2 of 10
Must do
Safe
The service must ensure environmental ligature and ligature point risk assessments are completed and actioned.
Regulation: Regulation 12 (Safe care and treatment)
⚠ There was no environmental ligature and ligature point risk assessment in line with national guidance.
Must-do action 3 of 10
Must do
Safe
The service must ensure risk assessments are completed and reviewed.
Regulation: Regulation 12 (Safe care and treatment)
⚠ Staff did not always complete and update risk assessments for each woman or take action to remove or minimise risks. Staff did not always complete risk assessments for each woman on admission/arrival, using a recognised tool, and review this regularly.
Must-do action 4 of 10
Must do
Safe
The service must ensure that triage waiting times are monitored to ensure that women and pregnant people are assessed within the required timeframes.
Regulation: Regulation 12 (Safe care and treatment)
⚠ We were not assured that managers monitored waiting times and made sure women could access emergency services when needed and received treatment within agreed timeframes and national targets. As there had not been any audit of the current triage system being used, we could not be assured that women were …
Must-do action 5 of 10
Must do
Safe
The service must ensure there are enough midwifery and medical staff with the right qualifications, training, and experience to keep women and pregnant people safe from avoidable harm and provide the right care and treatment.
Regulation: Regulation 12 (Safe care and treatment)
⚠ 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. The service did not have enough medical staff with the right qualifications, skills, training and experience to keep women …
Must-do action 6 of 10
Must do
Well-led
The service must ensure that all incidents are reported internally and externally in line with trust policy and national requirements, investigated thoroughly and that learning from incidents is shared.
Regulation: Regulation 17 (Good governance)
⚠ The service did not manage safety incidents well. Staff did not always recognise and report incidents and near misses. Managers did not always investigate incidents and share lessons learned with the whole team and the wider service. Incidents were not consistently reported and there was limited evidence of learning from …
Must-do action 7 of 10
Must do
Well-led
The service must ensure that key and fundamental audits are completed so that performance can be monitored and actioned.
Regulation: Regulation 17 (Good governance)
⚠ The service was not completing key audits at a local level. For example, there were no audits of the triage process, CTG and fetal wellbeing, the SBAR tool and maternity records. There was a lack of auditing of key areas of performance (MEOWS, CTG, records), which meant that there was …
Must-do action 8 of 10
Must do
Well-led
The service must ensure that specific lead roles for obstetrics, such as obstetric clinical lead, are job planned and in place.
Regulation: Regulation 18 (Staffing)
⚠ There was no clinical lead for obstetrics and this post had been vacant since August 2022. At the time of our inspection there were no formally identified leads for clinical governance, labour ward or fetal monitoring.
Must-do action 9 of 10
Must do
Safe
The service must ensure that staff are trained in high dependency level 2 care.
Regulation: Regulation 12 (Safe care and treatment)
⚠ Evidence showed the service did not have any high dependence trained midwifery staff to support women and birthing people requiring enhanced observation.
Must-do action 10 of 10
Must do
Well-led
The service must ensure the culture within the service significantly improves so that it does not impact upon service user safety and care.
Regulation: Regulation 18 (Staffing)
⚠ Staff did not always feel respected, supported, and valued, but most were focused on the needs of women receiving care. The service did not always have an open culture where staff could raise concerns without fear. The pulse survey identified an ongoing divide in experiences working within the maternity service …

Should-do actions (7)

Recommended improvements to enhance service quality.

Should-do action 1 of 7
Should do
Safe
The service should ensure all staff have training on how to recognise and report abuse and all staff know how to make safeguarding referrals.
Should-do action 2 of 7
Should do
Safe
The service should ensure all staff use infection prevention and control measures to control infection risk.
Should-do action 3 of 7
Should do
Safe
The service should ensure that all members of the MDT attend delivery suite ward rounds and safety huddles.
Should-do action 4 of 7
Should do
Well-led
The service should ensure all staff receive an annual appraisal.
Should-do action 5 of 7
Should do
Safe
The service should ensure there is a record system that is clear, complete, and up to date to enable staff to provide safe and effective care.
Should-do action 6 of 7
Should do
Safe
The service should ensure there is a single prescribing system to minimise the risk of prescribing and administration of medicines errors.
Should-do action 7 of 7
Should do
Well-led
The service should ensure that duty of candour is carried out for all eligible incidents.

Location details

CQC ID: RGP75
Local authority: Norfolk
Region: East

Inspection report

Type: Location
Date: 31 May 2023
Rating: Requires improvement
Actions: 10 must-do 7 should-do
AI-extracted 2 Jun 2026

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