The Royal Bournemouth 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

This means we looked for evidence that the service’s leadership, management and governance assured high-quality, person-centred care; supported learning and innovation, and promoted an open, fair culture.

This is the first assessment for maternity services since the move of services to The Royal Bournemouth Hospital. This 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.

During the assessment we identified a breach of regulation 17 for governance.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

We scored the service as 2. The service did not have a clear shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of women and their communities.

The maternity service’s vision was “improvement and movement to provide the best patient-centred, safe care”, with key objectives aligned to the National Maternity Strategy programme around safety, compassion, equality and collaboration. Removed

Information provided stated an improvement approach was ongoing to support maternity services and to understand the improvement journey.

A maternity improvement driver diagram was provided with what the maternity service wanted to achieve. We were not provided with an action plan or preliminary timeframes for completion of the review at the time of the assessment. Following the assessment the trust told us the senior leadership team were currently in the process of developing an action plan to implement the identified change ideas outlined in the driver diagram.

The service was working with the operational development team to update the maternity vision and strategy to reflect the move to the BEACH building. Staff were being encouraged to answer a short survey on the service to identify what inspired them and what made them proud. The senior leadership team were due to meet in October 2025 to review the next process.

However, staff told us they did not feel listened to by the senior leadership team. Staff told us senior leaders could become defensive when challenged and not all staff felt valued. Staff appeared frustrated that most senior leaders were unable to support clinically, and there was a lack of direct communication between senior leaders and midwifery teams.

Staff told us they had continuously raised concerns around working back-to-back shifts, long hours, shifts running over 12 hours, lack of breaks and shifts being uncovered. Staff told us they were left feeling “burned out” and “tired”. Senior leaders told the assessment team they were aware staff were unhappy and were improving communication and staffing.

The last staff survey was completed between September and November 2024 prior to the maternity service’s move to the new building. The results from this survey were reviewed by the senior leadership team in May 2025. The review identified the same concerns we found during the assessment. The service had an action plan in place to address the concerns and work was in progress.

Following on from the survey results, there was the introduction of the patient first huddles, the on-call rota for midwives and information on the meal break etiquette was reinforced. However, this did not provide staff with assurances around gaps in staffing.

We scored the service as 2. Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

Staff told us they felt there was a disconnect between maternity staff and senior leaders. During our assessment we found information and changes were not always communicated to staff, with staff feeling they were not heard. Staff told us they were frustrated senior leaders did not support the maternity teams clinically, giving us examples of being told by managers, “They would be no help if they worked clinically” or “they were unable to”. Senior leaders told us they had not worked clinically for some time and had not updated their clinical skills. Therefore, they did not always experience first-hand what staff were experiencing.

There was a clear management structure with defined lines of responsibility and accountability. The leadership team provided listening events for staff and completed daily visits to the maternity unit. However, on the day of the assessment some staff could not name the Director of Midwifery when asked by the inspection team.

Staff shared concerns that band 8 staff and senior leaders were not visible on the maternity unit, which left them feeling unsupported.

Senior leaders felt they were listening to staff and told us there were monthly staff listening events and a poster highlighting “You Said, We Did”. There was also a weekly tea trolley event where staff were encouraged to tell senior staff what they were most proud of and what challenges they faced. However, staff we spoke to preferred more hands-on support and most staff we spoke to did not feel their concerns were always addressed or followed up.

During the assessment we heard from staff that they were unhappy. This was acknowledged by senior leaders who told us they were aware staff were not happy and confirmed there was a high sickness rate with staff being off with stress and anxiety. Senior leaders had completed a staff feedback action plan to outline ongoing actions to support staff. The action plan was separated into 4 areas workforce, patient flow, communication and information, and wellbeing. Although there was a plan in place we found most actions for workforce and wellbeing had not yet been completed and staff continued to feel overwhelmed.

The plan was colour coded and showed 2 out of 6 areas of concern for workforce had been substantially or fully completed, 1 out of the 6 actions identified for wellbeing had been substantially or fully completed. put into place. For patient flow and communication and information most actions were coded to identify they had been completed or partially completed.

Senior leadership had either completed been fully completed or partially completed actioned most areas within patient flow and communication and information. However, there were areas within patient flow that had been completed but had not alleviated staff concerns or safety for example, the increase in women attending maternity triage staff a

Staff returning from long-term sickness told us there had been a work plan set up for their return. However, this was not always maintained due to the continued staff shortages during each shift.

The 2025 Pulse survey (a survey designed to gather the insights and experience of staff) identified that 51% staff members were positive about the maternity services and 49% were negative. Staff were unhappy about the lack of support from senior leaders, poor communication and a high workload. Staff felt the service needed to improve communication, staffing and morale. The service provided a staff feedback action plan. Actions included the head of midwifery to attend safety huddles, leaders to be more visible by walking the floor, and to provide better lines of communication.

We scored the service as 2. Staff did not always feel able to speak up and that their concerns would be heard and acted on to drive improvement.

There were processes to promote freedom to speak up (FTSU) and direct feedback from the FTSU guardian to the maternity directorate. The leadership team met quarterly with the trust’s FTSU guardians to discuss themes and concerns. The FTSU escalated directly to the director of midwifery or head of midwifery.

The trust told us there were 20 concerns specific to maternity were raised between September 2024 to September 2025. One of the concerns received was anonymous.

Themes recorded were attitudes and behaviours, process and procedure, worker wellbeing and patient safety. There were 19 out of the 20 cases responded to within 48 hours by the team.

However, a large number of staff we spoke to during the assessment told us they did not always feel able to raise their concerns with the FTSU.

Prior to our assessment, we received whistleblowing concerns from staff around low staffing levels and staff feeling unheard, undervalued, stressed, and experiencing low morale.

The FTSU were reported to have completed walk abouts on the maternity units to speak with staff and attended a quarterly meeting with senior leaders to share themes but can and do escalate if cases require it in between these dates.

We scored the service as 3. The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for staff.

Staff and leaders told us the service promoted equality and diversity within their daily work. The service had an equality, diversity and inclusion policy.

The trust provided implicit bias and inequalities training, which promoted staff wellbeing and highlighted how professionals from a diverse background faced barriers within career progression. The training discussed improving support for colleagues and developing a deeper understanding of racism and inequality in healthcare.

The trust had actively recruited international midwives and recognised the value they brought to the service regarding their knowledge and experience. The service had provided international midwives with an initial pre-meeting contact and an extensive supernumerary and induction period. They were given a preceptorship framework competency document, which was a guide for the midwives on workplace information, orientation to maternity, clinical skills, training and competencies, supporting them to develop from new graduates to established nursing professionals.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have clear systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes.

Governance systems were not always operating effectively to ensure risk and performance issues were identified, escalated appropriately, and addressed with timely actions.

During the assessment we were informed there were no concerns in regard to medical staffing and there were substantive consultants in post and minor gaps reported within the on-call medical rota and service delivery. However, medical staffing was high on the risk register and there were delays on women receiving a medical review within maternity triage.

The service acknowledged that there had been an increase in incidences for post-partum haemorrhage (PPH) rates since the move to the new building and were working with staff to reduce high rates. A new post-partum haemorrhage (PPH) proforma and weekly PPH multidisciplinary meetings had been introduced, to support their work.

The service told us they were seeing rates of PPH levels reducing and the covering information provided by the senior maternity team stated there had been an improvement on PPH rates against the national target, with rates in June 2025 being 40 in every 1,000 women and in July 2025 it was reported they reduced further and were 30 in every 1,000 women.

However, there were inconsistencies and a lack of clarity with the reported PPH data. For example, the information provided differed to the information reviewed within the maternity and neonatal reports for July and August 2025. This highlighted PPH rates had increased, with July 2025 being 48 per 1000 and August 2025 reported as 48.9 per 1000. Additionally, in the September 2025 multidisciplinary (MDT) risk meeting minutes there was a case of PPH reported to be 3100mls.

This inconsistency in data reporting meant the trust could not be assured regarding their performance around PPH rates and whether their actions had been effective in driving improvement or whether further work needed to be done. High PPH rates could potentially lead to maternal death and increased complications for the newborn baby.

The discrepancies had a large impact on governance. Inconsistencies within data could potentially make it difficult to identify where there are themes and trends and why the service was not in line with national targets.

The service told us following concerns raised regarding the maternity triage telephone line, there was a process for ensuring calls were answered or queued, with a return call made as promptly as possible. The call waiting system kept queued calls waiting and staff called women back if they hung up. The service stated that this process, along with the ability to divert calls to maternity, provided a suitable safeguard to answer calls as promptly as possible. The telephone triage line was on the maternity risk register, with the risks identified as calls going unanswered, not having a timely response or urgent calls not going through to the appropriate person. This demonstrated that previous mitigation and processes were not always effective. However, following the assessment the trust provided information to demonstrate action was being taken to drive improvement.

The trust board received monthly updates from the director of midwifery (DOM) through the quality committee safety champions report. The service completed a monthly maternity and neonatal report in order to provide information on alerts, advise and assure the clinical governance group. All maternity issues, learning and actions identified through incidents, risks, audit and policies were fed into the maternity and neonatal meetings. These meetings informed the quality report and the maternity and neonatal quality and safety oversight group, Safety Champions, board and the LMNS.

Perinatal mortality review tool (PMRT) meetings were collaborative monthly multi-disciplinary review meetings held online between the service and another local within the LMNS to provide a peer review approach.

Leaders monitored key safety and performance metrics. They identified and escalated relevant risks, issues and actions to reduce their impact. An audit programme provided assurance of the quality and safety of the service. Local audits, such as clinical and compliance audits, were undertaken with associated action plans attached.

We scored the service as 3. The service understood their duty to collaborate and work in partnership, so services work seamlessly for women

Leaders attended regular meetings with the Local Maternity Network System (LMNS) to review governance and incidents and worked with the Maternity and Neonatal Voices Partnership (MNVP) to contribute to decisions about care in maternity services. Meeting minutes showed current work being undertaken between the local MNVP, maternity service and the LMNS.

We scored the service as 3. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcomes and quality of life for women. They actively contributed to safe, effective practice and research.

All staff were committed to continually learning and improving services. They had a good understanding of quality improvement (QI) methods and the skills to use them. To demonstrate that, the service had initiatives and plans in place to support the recommendations made in the avoiding term admissions into neonatal units (ATAIN) programme. The service also had several quality improvement projects being undertaken by staff. For example, there was a QI programme to decrease admissions, with one project to improve the birth environmental temperatures, skin to skin with parents, and staff training.
The service was committed to improving services by learning. Staff contributed to programmes such as the patient safety incident response framework (PSIRF) and multidisciplinary review meetings, that provided reflection and learning.

The service had strong external relationships to support improvement and innovation. We saw evidence of regular engagement of leaders and service users to review and improve the service, such as the Maternity and Neonatal Voices Partnership (MNVP) steering group. For example, prior to the move to the maternity unit, the MNVP completed 15 steps of the new maternity unit with senior leads.