North Middlesex University Hospital

On this page

• 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 last assessment, we rated this key question inadequate. At this assessment, the rating has improved to requires improvement. This meant there had been an improvement in leadership and culture however, there were still some shortfalls that impacted on the delivery of high-quality care.

The service was in breach of legal regulation in relation to the governance, leadership, culture and workforce equality, diversity and inclusion within the service.

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.

Staff did not always feel respected, supported and valued. However, the service had a shared vision and strategy. 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.

North Middlesex Hospital was previously run by North Middlesex University Hospital NHS Trust and recently merged with the Royal Free London NHS Trust on 1 January 2025. The Royal Free London NHS Trust had a 5-year maternity vision and strategy produced in 2022 for what it wanted to achieve and objectives to turn it into action. The maternity service at North Middlesex Hospital had adopted this. The strategy was developed with all relevant stakeholders such as women and birthing people, staff and representatives of the maternity and neonatal voices partnership (MNVP).

The purpose of the maternity service was to provide high quality, respectful and individual care for women and birthing people, as well as their babies and families, during their maternity journey. They also aimed to ensure a high quality, inclusive working environment for their staff.

Their governing objectives were; excellent health outcomes, outstanding patient experience, outstanding experience for staff, a sustainable organisation. The strategic priorities to achieve this were:

• Personalised Care and User Involvement
• Continuity of Care and Equality of Care
• Empowered and Engaged workforce
• Building our teams capability and providing career opportunities
• Leading research, innovation and practice
• Delivering on the outcomes of North Central London "Startwell" programme

The trust also demonstrated how they aimed to achieve, measure and share the outcomes of this vision and strategy.

The leadership team planned to host a maternity strategy workshop in the future with the now merged organisations to review priorities using a co-productive approach.

The service also had values for staff to follow which were; positively welcoming, actively respectful, visibly reassuring and clearly communicating. Staff we spoke with were aware of the trust values.

Most managers and staff reported an improvement in the culture within the service however, a number of staff still did not feel supported, respected, valued and had experienced incidents of bullying. This was not an improvement since the last inspection. Staff reported that they had raised their concerns to service leaders however, leaders did not take immediate action to prevent and address bullying, discrimination and harassment at all levels.

Leaders were aware of how poor culture within the service could affect the quality of people's care and the need for cultural improvement within the service. This was identified as a risk on the service's risk register. In response to this risk, the service undertook a SCORE survey in March 2024 which is an internationally recognised way of measuring and understanding culture. The results were analysed, and a cultural improvement plan was developed. The three main themes for improvement were; to improve communication, staff engagement and staff morale. The cultural improvement action plan included but was not limited to the introduction of an equality, diversity and improvement champion within maternity who was in place at the time of inspection, introduction of staff appreciation initiatives and staff forums. To support with the cultural improvement plan, leaders also reported that they had commissioned an external organisational development company to support maternity cultural improvement.

The service had a history of unstable leadership resulting in slow progress in implementing improvement within the service. However, the service now had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. Leaders had the skills, knowledge, experience and credibility to lead effectively.

Maternity services sat within the Women's, Children's, Cancer and Diagnostics division. Maternity had a trust level leadership structure since the hospital became part of The Royal Free London NHS Trust and a hospital level maternity leadership structure. There was a divisional quadrumvirate which consisted of the Divisional Director of Operations, Divisional Clinical Director, Divisional Director of Midwifery and Divisional Director of Nursing. The divisional quadrumvirate worked alongside a maternity directorate quadrumvirate which consisted of the General Manager for Women's and Children, Clinical Director (Obstetrics and Gynaecology), a Neonatal Lead and an Associate Director of Midwifery (a role also known as head of midwifery). The service had a history of unstable leadership, the director of midwifery currently in post started at the hospital in November 2024, after the post had been vacant since May 2024. Staff welcomed the recruitment of the new director of midwifery, support from the trust level maternity leadership and a more stable leadership. Staff also reported that leaders were now more visible and approachable.

Leaders had the experience, skills and abilities to run the service. They understood and managed the priorities and issues the service faced. Since the last Care Quality Commission (CQC) inspection in May 2023, leaders reported that they felt they had more `buy in' from the trust board regarding maternity services and work was ongoing to ensure board assurance. In response to the last CQC inspection, the service had developed an extensive improvement plan. The service had made some progress on this plan however, progress in completing all actions were slow with a lot of actions still open, which staff felt was largely due to unstable leadership.

The service was supported by maternity safety champions who undertook regular walks around the unit and were heavily involved in the improvement plan that was ongoing within the service. The service held monthly maternity and neonatal safety champion board meetings which were chaired by the chief nurse. We reviewed minutes from this meeting, the meeting covered topics such as the risks within maternity, updates from all areas within the service and an update on the progress of the improvement plan.

Leaders understood how health inequalities affected treatment and outcomes for women and birthing people and babies from ethnic minority and disadvantaged groups in their local population. We observed this being discussed at relevant governance meetings and some of these meetings were attended by representatives of the local communities.

The service was fostering a positive culture where people felt they could speak up and their voice would be heard.

Women and birthing people, relatives, and carers knew how to complain or raise concerns. Women and their families could give feedback on the service and their treatment and staff supported them to do this. We observed posters with QR codes around the unit encouraging women and birthing people and their families to give feedback on their care both in English and other languages. The service provided evidence of leaflets produced in multiple languages, to ensure they catered to the diverse population of women and birthing people they provide care to. This was an improvement since the last inspection.

The service had an open culture where women and birthing people, their families and staff could raise concerns without fear. Staff on the maternity ward reported that women and birthing people were becoming more responsive in completing the friends and family test (FFT), the response rate in December 2024 was 63%.

The service also took part in the Care Quality Commission (CQC) maternity survey 2023, published in 2024. The service performed at about the same level as other trusts in 21 questions, better than expected in 1 question and worse than expected in 1 question. The question the service performed worse than expected in was around being sent home in labour.

Staff knew how to acknowledge complaints and, women and birthing people received feedback from managers after the investigation into their complaint. Managers investigated complaints, identified themes and shared feedback with staff. Learning from these complaints were then used to improve the service. The service had 7 formal complaints raised between November 2024 and January 2025, 5 of which were open. The themes reported by women and birthing people included delay in discharge, poor communication, lack of support from staff and unprofessional attitude displayed by staff. Of the 5 complaints that were open none of them were overdue a response.

Staff understood the duty of candour. They were open and transparent and gave women and birthing people and families a full explanation if and when things went wrong. However, the service declared themselves non-compliant in respect to the duty of candour as part of the clinical negligence scheme for trusts (CNST): maternity incentive scheme (MIS). The MIS is a financial incentive programme designed to enhance maternity safety within NHS trusts. It rewards trusts that can demonstrate they have implemented a set of core safety actions.

Leaders reported that the service was currently working on the culture of staff speaking up and appropriate action being taken in a timely manner as this was a concern raised by staff. Staff were encouraged to raise concerns, and the service promoted the value of doing so. The service had a staff voices forum which was held monthly and was open to all maternity staff. The service described the forum as "a safe space where your voice is heard, your professional development is supported, and patient care continually improved". Information shared in this forum was confidential, the service provided the meeting minutes for the last 4 months. The minutes were limited to topic headings and non-confidential information to maintain confidentiality, but we found that the forum was well attended, and covered topics such as challenges within the services, updates on improvements and an opportunity for staff to raise concerns. There was an action log in response to the topics discussed that required action and topics that required action were escalated to senior leadership.

The service also held monthly staff meetings in individual areas within the service, this included community, maternity wards, triage and labour ward. Staff were able to attend these meetings in person and virtually. Meeting minutes that we reviewed showed that the meetings were well attended and the topics discussed were comprehensive.

Results from the NHS staff survey 2023, published in 2024 showed that staff within maternity services scored below the overall trust average in the `we each have a voice that counts' question which supports reports from staff about the culture of speaking up within the service.

The service had a freedom to speak up champion and staff knew how to access them. Staff had raised 6 concerns to the freedom to speak up guardian between January and December 2024. Of the 5 concerns there was one case that was still open and under investigation. The data provided by the service showed that the concerns were escalated and managed by leadership who would work with the complainant to resolve the concerns raised.

The service did not always value diversity in their workforce. Leaders reported working towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff and leaders we observed onsite were representative of the population of people using the service. However, staff we spoke with did not always feel that the service valued diversity and reported that to develop within the service “you had to be liked” as opposed to development opportunities being awarded based on competence.

The NHS survey 2024 included trust specific data on Workforce Race Equality Standards (WRES) and Workforce Disability Equality Standards (WDES). This data is representative of the Trust as a whole and not specific to maternity services. The finding showed only 54% of white staff and 51% of staff from other ethnic groups believed that the organisation provided equal opportunities for career progression or promotion. Findings from the hospital workforce disability equality standards question showed 36% of staff with long-term conditions or illnesses and 53% of staff without long-term conditions or illnesses believed that the organisation provided equal opportunities for career progression or promotion. Which highlighted there was room for improvement with workforce equality.

Leaders took action to review and improve the culture within the service in the context of equality, diversity and inclusion. As part of the cultural improvement action plan, the service had introduced the Capital Midwife Anti-Racism Framework to improve equality and equity within the service. The service had also put an equality, diversity and inclusion (EDI) champion in place and work was being done to introduce maternity specific EDI training.

According to the trust website there were equality networks that staff were actively involved in, this included; BAME – for black, Asian and ethnic minority staff, Ability at the Free – for staff with long-term conditions or disabilities, Women’s Network, Flourish at the Free – for colleagues in bands 1 to 5 and LGBT+ Friends. It was unclear if this was also embedded at North Middlesex University Hospital since the merger.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. Staff did not always submit national data in a timely manner.

Leaders did not operate effective governance processes, throughout the service and with partner organisations. The governance team was not yet fully established and functioning, the team was working hard to cover the shortfall in vacancies and delays in incidents being actioned and closed promptly. The governance team was led by a quality and safety lead which was an interim position. The team currently included a band 6 quality and safety midwife, band 7 guidelines midwife, band 7 audit midwife and a band 3 admin support staff. There was another band 7 midwife due to join the team in May 2025 and ongoing recruitment for other governance roles within the team. This had been identified as a risk on the risk register.

The service had a risk register that currently had 19 opened risks. The risk register included a title, risk approval date, risk owner, description of risk, review date and the risk rating score. The risk register included the risks we identified on inspection which provided assurance that leadership and staff were aware of the risks within the service. Staff we spoke to were aware of the top 3 risks on the risk register and we observed clinical governance boards across the unit with this information. Managers in clinical areas within the service reported that they had access to the risk register and the ability to add risks. However, we observed risks with lower risk ratings that had been on the register since 2017. This meant we could not be assured that these risks were being managed effectively and in a timely manner.

Staff at all levels had regular opportunities to meet, discuss and learn from the performance of the service. The governance team had daily and ad-hoc meetings with senior midwifery teams and matrons to review, validate and close incidents reports. The service had 49 open incidents awaiting investigation and 6 serious incidents open as of December 2024. Leaders told us the service held weekly meetings between the divisional governance manager, quality and safety team and senior leadership team to review the incidents and liaise with incident owners to retrieve feedback and evidence completed actions. However, the service did not supply minutes for these meetings, so it was unclear how actions from these meetings were collated and monitored.

Representatives from maternity attended the Women's, Children's, Cancer and Diagnostics Governance board in which they presented an update on incidents, ongoing recruitment and risk within the service.

Data and notifications were not always submitted to external organisations. The service did not always submit qualifying early notification cases to the NHS Resolution early notification scheme. This scheme was developed to support the National Maternity Safety Ambition to halve maternal and neonatal deaths and reduce significant harm. However, the service referred all qualifying cases to the maternity and newborn safety investigations (MNSI). All NHS trusts are required to tell the MNSI about specific safety incidents that happen in maternity which are then investigated and where relevant safety recommendations are made. The service had referred 3 cases to the MNSI in the last 6 months. We saw evidence of an action plan being created and actively worked on based on the recommendations made by the MNSI in response to a referral.

Data submitted by the service showed that they held monthly multidisciplinary perinatal mortality review tool (PMRT) meetings and used the perinatal mortality review tool to review the care and report about deaths that occurred within the service. Collated data was submitted to Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK) as required. However, the trust did not produce quarterly board report of PMRT data to the trust board in line with the clinical negligence scheme for trusts (CNST): maternity incentive scheme (MIS).

The trust was not compliant with the CNST year 5 safety actions and have declared non-compliance in 4 of the 10 safety actions for year 6 also. The service reported that the trust and the North Central London (NCL) local maternity and neonatal system (LMNS) are supporting the service with an action plan to address this. Particularly around the fetal monitoring within the saving babies lives care bundle (SBLCB) v3 and avoiding term admissions into neonatal units (ATAIN) which are schemes to reduce perinatal mortality and to reduce the harm leading to avoidable admissions to the neonatal units for babies born after 37 weeks.

The service's information systems were not always integrated which resulted in delayed data submissions to external organisations. The service had issues pulling data from the current maternity electronic patient record (EPR) system. Which led to a significant amount of time being spent, manually accessing and correcting data to be submitted to the local maternity and neonatal system (LMNS) dashboard, and other external submissions resulting in reporting deadlines being missed.

The LMNS dashboard is a dashboard where key performance indicators (KPI) are displayed for review and managers could see other maternity service within the trust and network for internal and external benchmarking and comparison. The service generally performed well in KPI's in comparison to other trusts in the North Central London integrated care system. In response to issues with data the service reported they had updated the coding within the system but there are discrepancies still outstanding although reduced. The service reported that the introduction of the new EPR system due to be rolled out in April 2025 will help resolve the issues with pulling accurate data.

Managers and staff carried out a comprehensive programme of repeated local audits to check improvement over time. Local audits included but were not limited to diabetes in pregnancy, antenatal and postnatal mental health and hypertension in pregnancy. These local audits were based on the National Institute of Health and Care Excellence (NICE) quality standards. Data submitted by the service showed that each audit had a lead clinician overseeing progress and a due date for submission.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. Staff share information and learning with partners and collaborate for improvement.

Staff and leaders were open and transparent, and they collaborate with all relevant external stakeholders and agencies. The service was currently on the maternity and neonatal safety improvement programme which was a programme to improve the safety and outcomes of maternal and neonatal care. The service was onboarded to the programme in July 2024 and was allocated both a midwifery and obstetric improvement advisor. The advisors reported that the service was very open and transparent, eager to make improvements with their support and are actively involved in the programme.

Leaders worked to understand the needs of the local population. Leaders worked with the local Maternity and Neonatal Voices Partnership (MNVP) to contribute to decisions about care in maternity services. The service recruited a MNVP maternity chair in November 2024 and has just recently recruited a neonatal chair. The MNVP worked with maternity services to bridge the gap with women that could be harder to reach. They did this by attending the maternity wards with translators and speaking to women directly to gain their experiences and attending community groups such as breastfeeding groups and nurseries. The MNVP attended and presented findings from the experiences of women and birthing people within the community at the maternity and neonatal board.

Since being recruited, the chair has been actively involved with the service and reports an open and positive relationship with the leadership within the service. The MNVP chair reported working closely and having regular meetings with the head of midwifery, consultant midwife and patient experience team to discuss patient experience and topics such as the Care Quality Commission maternity survey results. The MNVP chair reported that the service was very responsive and that they feel like a valued member of the team which was an improvement since the last inspection.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for people. Staff actively contribute to safe, effective practice and research.

Staff were supported to prioritise time to develop their skills, the service provided evidence of career progression and additional learning sessions that were held weekly and facilitated by the recruitment and retention midwife.

All staff were committed to continually learning and improving services. They had a good understanding of quality improvement 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 ATAIN programme, the service had several quality improvement (QI) projects being undertaken by staff. This included a project where they implemented a neonatal risk sepsis calculator which reduced antibiotic use in the first 24 hours of life in babies at risk of sepsis. Another QI project was conducted to improve staff knowledge around the importance of stable temperatures for pre-term babies, this project saw an improvement in patient safety and won 2nd place at a quality safety conference.

Staff and leaders engaged with women and birthing people to also improve their learning, the maternity ward introduced a QR coded information board for new mothers and birthing people, and fathers as a result of a QI project led by midwives. The board contained information on when to feed your baby, safe sleeping, postnatal fitness for new mother, dads matter UK and men's mental health etc.

Leaders encouraged innovation and the service had strong external relationships that support improvement and innovation. The service won a bid for enhanced maternity continuity of career (MCoC) funding from the local maternity and neonatal system (LMNS). With this funding the service planned to introduce a MCoC community team that will allow women and birthing people to have continuous care by core midwives throughout the antenatal, intrapartum and postnatal period.