Royal Sussex County Hospital

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our previous inspection we rated this key question as inadequate. At this assessment, the key question has been rated as requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. We assessed 7 quality statements.

The service was in breach of legal regulation in relation to the governance of the service. The breach was in relation to risks not being addressed in a timely manner, staff access to patient information, assurance through auditing systems, setting of targets and benchmarking processes.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. Changes in the leadership team had caused some instability within the department. Some departments felt they were not integrated into the wider service. Due to staffing pressures and leadership instability, there had been less focus on innovation.

However, the service focused on improvement across the organisation and local system. leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were mostly visible, knowledgeable and supportive. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Women with protected characteristics felt supported. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The divisional vision was, “To be a leading provider of maternity care where supportive compassionate care and kind communication create a safe, empowering and personalised experience for all families.”

The divisional goals were aligned with the NHS Three Year Delivery Plan for Maternity and Neonatal Services (2023) and the University Hospitals Sussex NHS Foundation Trust Maternity Improvement Plan. The goals included delivering the highest standards of safety and quality of care, reducing health inequalities, workforce development, enhancing service user experience, increasing innovation, technology, community, and partnership.

Service users and staff were invited to contribute to the goals and vision. The trust used key words taken from feedback from the Friends and Family Test, Maternity and Neonatal Voices Partnership (MNVP) quarterly survey, and MNVP walkarounds. Key words were also used from the clinical team staff survey, feedback given to the recruitment and retention midwives and following a culture event held in June 2024.

The words were then collated, and service users and staff were asked to vote on what they felt were the most important to include within the trust vision.

The maternity unit had been through a very difficult period where the culture had been poor, and the pressure and scrutiny of the staff and unit had been very intense. Staff reported that things had improved over the past 6 months and increased staffing and leadership stability had been improving.

The assessment team were welcomed into the unit by all staff members. Staff were willing to talk to us and be open about what the service was like. This showed an open work force who welcomed review.

We saw a process for escalating any concerns over performance issues and staff felt able to challenge each other and take ownership of the department. We saw there was a ‘no blame’ attitude to incident reporting and in response to incidents. Senior staff understood the importance of staff being able to raise concerns without fear of retribution and we saw this was embedded across the unit.

The service celebrated staff and team success and supported good practice through meetings, maternity newsletters, a private telephone messaging group and team aways days.

The evidence showed some shortfalls. There had been several changes in the leadership team which had caused some instability within the department. Some departments felt they were not integrated into the wider service. The service now had inclusive leaders who understood the context in which they delivered care and treatment. Leaders had the skills, knowledge, experience and credibility to lead effectively.

The senior leadership team felt the executive team understood and supported their vision for the maternity service however, they acknowledged that there had been barriers to understanding and acting on risks. Staff we spoke with across the department described raising the same issues and risks often and not feeling heard.

The leadership and reporting structure had led the unit to feel unsupported. Some parts of the unit we spoke with felt disconnected to the wider service. These included the staff at Sussex House and the early pregnancy unit. Staff told us they had felt unable to access support when needed, for example some staff described several changes in leadership and process which had made them feel unsure of who to report too.

The trust had introduced a new leadership reporting structure, and the team were supported by a head of midwifery who covered RSCH and Princess Royal Hospital (PRH), and a director of midwifery who covered the four hospital sites across the trust, It was designed to improve reporting lines. The division had a quadrumvirate medical leadership structure who oversaw the division as a whole and fed back to the chief of service. The service had recently implemented a new divisional clinical operating model which included overarching cross site clinical director roles alongside dedicated site-specific medical leadership.

Staff told us their ward managers; matrons and the head of midwifery were visible and approachable on the maternity unit. Some leaders worked clinically with the maternity unit team and staff reported this had improved communication and trust in the leadership team, however the staff at Sussex House and the Early Pregnancy Unit (EPU) felt they often worked in silos and described feeling not fully integrated into the wider service.

The director of midwifery had direct and regular access to the trust board through a series of meetings and could routinely monitor information about quality, including safety and take necessary action to improve quality.

The trust had focused on staff wellbeing and recruitment and retention over the last 3 years, resulting in a reduction in midwifery vacancy from 22% in 2022 to 11% in February 2025.

A team of clinical maternity safety champions had direct contact with the leadership team, executive and non-executive safety champions and shared information with clinical teams. Alongside this, the trust had launched a maternity safety forum chaired by the chief nurse who was executive maternity safety champion. The most recent meeting was held on 4 February 2025 and included reviewing previous listening events, recruitment and retention, career progression pathways, staff wellbeing, communication methods, estates and clinical pathway improvements.

The maternity service had a team of professional midwifery advocates (PMA), who provided pastural support and restorative supervision to staff. All midwives had an allocated PMA; support was also offered to support workers by the PMA team.

In the event of an incident, debriefing was facilitated by trauma and risk management (TRiM) trained practitioners from both medical and midwifery backgrounds with individual support and counselling services available. The TRiM practitioners were trained to deliver psychologically informed responses to traumatic events.

The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff we spoke with during the assessment told us they felt able to speak with leaders about difficult issues and when things went wrong. Staff told us when practice needed to be improved there was a no blame culture and they were supported to learn and develop within their roles.

In the past staff had not felt able to speak openly and to address this the trust had employed an external and independent freedom to speak up guardian. This was a pro-active approach, and staff had reported they felt more able to raise concerns as a result. Staff knew how to contact them and understood their role. We were given examples where staff had resolved issues by approaching managers and felt safe and supported to do so.

The evidence showed a good standard. The service valued diversity in their workforce. Staff worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

The department worked with system partners and service user groups to better understand the needs of service users from diverse groups and co-produce improvement.

In February 2025, the trust had held a race equality week with the theme of every action counts. It aimed to address race inequality in the workplace and raise awareness. There was also a LGBT+ history month in February 2025 themed around activism and social change, this included weekly newsletters highlighting LGBT+ people who had created social change from across the centuries.

Staff had access to monthly hypnotherapy, mini meditation sessions and financial wellbeing webinars.

The evidence showed significant shortfalls. The service did not always have clear responsibilities, roles, systems of accountability or good governance. Staff did not always act on the information about risk, performance and outcomes, or share this securely with others when appropriate.

A temporary leadership structure had meant the support and engagement within clinical teams had been a challenge. Improvements have been made in the last 6 months. These included a divisional monthly staff newsletter, listening events for all services and the roll out of check in surveys for perinatal teams. The department also held a perinatal culture and vision event in June 2024.

The unit did not have a comprehensive audit schedule and although one off audits were completed, there was a lack of continuation to gain assurance that the department was improving. For example, patient records audits and audits to identify if sepsis was being identified and treated appropriately. We were given examples where leadership had undertaken audits and more recently a pilot to introduce a second obstetric theatre. Leaders gained evidence of why changes were needed within the department which were presented, however at the time of assessment this had still not been implemented.

The trust did benchmark against national targets for the required audits. These included compliance with MBRRACE, the MSSP and the response to Ockenden requirements. However, they did not effectively use targets and benchmarking to ensure that the department was maintaining or improving outcomes for women.

The systems to ensure routine checks on medicines, cleaning checklists and audit were not embedded or used effectively to monitor for poor compliance.

Staff did not have access to up-to-date policies and guidance. The divisional meeting structure fed into the executive performance and quality meeting where any concerns were taken back to the divisional meeting the following week. We reviewed several meeting minutes and found that they had a clear role in the oversight of maternity services. However, we saw actions from meetings were not always managed in a timely way and often the same concerns were mentioned without a clear action plan. An example of this included was the large number of policies and procedures being outside of review dates.

The department had a risk register that was regularly reviewed. The top three risks the lack of a second theatre, delays in women receiving pregnancy growth scans and workforce pressures and increased activity and acuity. Although these were reviewed and we saw that some of the risk was identified, there was limited mitigation and ongoing delay in resolving the risk. For example, the identification of a need for a second theatre was fist added to the current risk register in 2022 and no permanent solution was in place. The environment at Sussex House was also on the risk register but no mitigations were in place.

The divisions completed a monthly quality report which detailed performance against safety metrics. This was shared at divisional governance meetings and at the monthly divisional quality governance forum. The trust recorded all birth information on the maternity dashboard. This covered organisational aspects, such as closures, activity, workforce and clinical indicators. The dashboard was reviewed at the monthly Maternity Safety and Quality meeting and at board level during the executive meetings. However, some of the maternity dashboard data was not benchmarked with targets, so the trust could not always be assured tell if the department was performing well against trust wide or national targets. The data was not scrutinised in an effective way as there was no clear indication if the data reviewed was better or worse than the previous recorded data.

The maternity service at RSCH was under a Maternity Safety Support Programme (MSSP) led by NHS England. The MSSP improvement plan was monitored as part of the maternity improvement group led by the chief nurse for the trust for compliance at bi-monthly meetings attended by the trust and relevant stakeholders. This included action plan and workstream reviews of multiple aspects of governance, safety and outcomes. Overtime the trust demonstrated changes and improvements; in February 2025, the report confirmed of 163 initial actions 91 were closed.

Oversight of compliance with the Perinatal Quality Surveillance (PQS) model was via the PQS monthly report which was also reported to the trust board monthly.

The trust used the Perinatal Mortality Review Tool (PMRT) and held meetings to discuss all cases. The trust planned to facilitate a merged meeting across all four trust sites to ensure a good level of oversight across the trust and to allow comprehensive peer review. The MNVP were also offered opportunity to attend these meetings and to learn from themes being presented and allow feedback from the service user.

The Maternity Services Survey 2024 looked at the experiences of 18,951 women, across 120 NHS trusts, who gave birth in February 2024 (and January 2024 for smaller trusts). Questionnaires were sent out between May and August 2024; responses were received from 281 people at University Hospitals Sussex NHS Foundation Trust. The survey looked at labour and birth, how staff treated them and care in hospital after birth, the trust scored about the same as other trust across all areas.

The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. Staff shared information and learning with partners and collaborated for improvement.

Service leaders spoke of great relationships with the local MNVP and encouraged them to attend meetings on site. The MNVP had regular contact with leaders to make a difference to services provided to women.

The MNVP conducted regular walk arounds of the maternity unit to speak to staff, women about their experiences and how things could be improved. They also engaged with charities and organisations to address inequalities and improve the experience and outcomes of women and families.

The evidence showed some shortfalls. Although we saw improvements throughout the service, there was still a lack of oversight due to not establishing routine audits, setting targets for the maternity dashboard data, lack of formal process for induction of labour (IOL) and CTG fresh eyes auditing and understanding how improvement can be monitored. Some of the risks identified in our last inspection were still evident and no solution was in place at the time of inspection. Due to staffing pressures and leadership instability there had been less focus on innovation.

Several audits were required to meet the standards of the UNICEF Baby Friendly Initiative. This initiative supported breastfeeding and parent infant relationships by working with public services to improve standards of care. The department were aware of what was needed to achieve the standard but currently it was reported that there was no capacity within the team to support this.

However, the trust had made many improvements since our last inspection. The trust told us they were on target to leave the Maternity Safety Support Programme by the end of 2025. The trust had implemented 264 out of the 272 requirements for the Ockenden (2020,2022) report recommendations).

There had been trust wide reflection and learning about harms for women and babies including neonatal deaths. Mortality rates were recorded as better than the national average and all neonatal death reviews were incorporated into relevant meetings including The Perinatal Mortality Review Tool (PMRT), Mothers and Babies: Reducing Risk through Audit and Confidential Enquiries (MBRRACE), Maternity and Newborn Safety Investigations (MNSI) and child death oversight panels. The trust board also received a monthly report. Learning was also shared system wide via the LMNS quality and safety forum and board.

The service had achieved 100% implementation of the saving babies lives care bundle in June 2024. The service met the requirements of the Clinical Negligence Scheme for Trusts (CNST), Maternity Incentive Scheme. The requirements were met for year 5 and the trust was on track to meet the requirement for year 6.

The service had improved the incident reporting culture and had worked hard to improve reporting and learning from incidents. Staff described a more positive culture around this which is an improvement on our last findings.

The service had introduced an ‘improvewell’ app which allowed staff to suggest ideas for improvement and keep everyone up to date with progress and implementation. It also included a tracker to allow staff to say how their day was going and launched quick surveys to see where improvements could be made. The uptake had been slow at the start, but audits revealed staff were more active in the month before assessment.

The trust had launched the ‘Womble Project’ in January 2024. The project aimed to cut down on waste by using out of date and unused medical equipment in education settings, such as simulation training.

Short staffing and high level of vacancy had impacted quality improvement and innovation. We saw several examples where projects had been placed on hold for safety reasons and having to redeploy staff members. An example is the improvement in reporting of red flags such as induction of labour delays. This project had stalled due to the redeployment of specialist midwives and managers. Although staffing had improved and the trust told us that specialist midwifes were deployed back to their roles by December 2024, so project work had started again.