Source · CQC inspection

The Tunbridge Wells Hospital at Pembury

Provider Maidstone and Tunbridge Wells NHS Trust Type NHS Healthcare Organisation Region South East Last inspected 2 Apr 2025

Overall rating: Requires Improvement  View full CQC report

Domain ratings

Five CQC key questions
Safe
Requires Improvement
Effective
Requires Improvement
Caring
Good
Responsive
Requires Improvement
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 2 April 2025
The service is not performing as well as it should and we have told the service how it must improve.
Maidstone and Tunbridge Wells (MTW) NHS Trust is a large acute hospital trust in South East England, legally established on February 14, 2000. The trust provides general hospital services and specialist complex care to approximately 560,000 to 760,000 people in West Kent and Northeast Sussex and employ over 8,000 staff. Maidstone and Tunbridge Wells NHS Trust’s core catchment areas are Maidstone and Tunbridge Wells and their surrounding boroughs. The trust has 3 registered locations: The Tunbridge Wells Hospital at Pembury Maidstone Hospital The Crowborough Birthing Centre The trust operates from …

Ratings by service

Maternity
Good
Sep 2024

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.

Warning notice Overall
We found that the service has made improvements and had met the actions of the warning notice.
· 28 Jul 2025 · CQC source
Warning notice Overall
We assessed service assessment group maternity at this location, to review the progress made against the warning notice that we served on the provider following the inspection in August 2023.
· 28 Jul 2025 · CQC source
Warning notice Overall
Following this assessment, we found the warning notice had been met and maternity was rated good overall.
· 2 Apr 2025 · CQC source
Warning notice Overall
We last assessed maternity services at Tunbridge Wells Hospital, Pembury in 2023, and it was rated to inadequate, and we served a warning notice.
· 2 Apr 2025 · CQC source

Breaches identified (3)

Breach Safe
At this assessment we identified a breach of regulation: 12 Safe Care and Treatment.
Regulation: Regulation 12 (Safe care and treatment) · 28 Jul 2025
Breach Overall
We found a breach of regulation in relation to: timely reviews of high risk women and birthing people on the wards who were waiting for their labour to be induced.
· 28 Jul 2025
Breach Safe
We found 1 new breach of the legal regulation safe care and treatment under the key question safe.
Regulation: Regulation 12 (Safe care and treatment) · 2 Apr 2025

Earlier inspection findings

pre-2024 framework · 6 must-do 4 should-do

Must-do actions (6)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 6
Must do
Safe
The service must ensure clinical observations, screening and testing are carried out in a timely way, reviewed, and any deterioration escalated.
Regulation: Regulation 12 (a)(b)
⚠ Staff did not always complete or update risk assessments and did not always take action to remove or minimise risks, meaning staff were not always able to identify and quickly act upon women and birthing people at risk of deterioration. The maternity triage did not have a standardised tool to …
Must-do action 2 of 6
Must do
Safe
The service must ensure staff complete all mandatory training, including safeguarding training as well as role specific training modules such as CTG training and are competent in carrying out CTGs.
Regulation: Regulation 12 (1)(a)(2)(a)(b)(c)(e)
⚠ Not all staff had completed mandatory training updates or their role-specific training, including basic life support, immediate life support, paediatric immediate life support, and safeguarding training. This meant staff did not always have the appropriate level of training to provide life-saving treatment. Cardiotocograph (CTG) training compliance was below the service …
Must-do action 3 of 6
Must do
Safe
The service must ensure that staff have carried out daily safety checks of emergency and specialist equipment.
Regulation: Regulation 15 (1)(e)
⚠ Safety checks of emergency equipment were not always carried out daily, with equipment checking sheets showing significant gaps in July and August 2023, and further gaps from January to May 2023.
Must-do action 4 of 6
Must do
Well-led
The service must ensure systems and processes for maternity triage are reviewed to deliver a safe service in line with national guidance.
Regulation: Regulation 17 (2)(a)(b)(c)
⚠ The maternity triage did not have a standardised tool to complete risk assessments for women and birthing people on arrival, with midwives using clinical judgement to assess and triage. The service was not following a policy-led timeframe to ensure who would have the most urgent assessment.
Must-do action 5 of 6
Must do
Well-led
The service must ensure there are effective governance systems and processes to identify and manage incidents, risks, issues and performance and to monitor progress through completion of audits, action plans and oversight of improvements and reduce the recurrence of incidents and harm.
Regulation: Regulation 17 (1)(2)(a)(b)(e)(f)
⚠ The maternity service governance processes and systems did not fully identify and manage incidents, risks, and performance, with a lack of audit to check improvements. Staff did not always complete or report incidents, and managers did not always investigate them, leading to insufficient learning. Incidents were often inaccurately graded, and …
Must-do action 6 of 6
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 sufficient numbers of suitably qualified, competent, skilled, and experienced midwives, leading to staffing levels not matching planned numbers and putting the safety of women and babies at risk. There were high vacancy, turnover, and sickness rates, and the service rarely reported 'red flag' staffing …

Should-do actions (4)

Recommended improvements to enhance service quality.

Should-do action 1 of 4
Should do
Well-led
The service should ensure the vision and values relate to the current model of maternity care and all staff understand and apply them to their work.
Should-do action 2 of 4
Should do
Safe
The service should ensure staff complete abduction drills and are confident in the process to follow.
Should-do action 3 of 4
Should do
Safe
The service should ensure all cleaning schedules and checklists are developed and completed to meet the needs of the service.
Should-do action 4 of 4
Should do
Safe
The service should ensure all medicines are stored and managed safely.

Location details

CQC ID: RWFTW
Local authority: Kent
Region: South East

Inspection report

Type: Location
Date: 16 February 2024
Rating: Requires improvement
Actions: 6 must-do 4 should-do
AI-extracted 3 Jun 2026