Luton and Dunstable 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 as inadequate. At this assessment the rating has remained inadequate. This meant there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

At our previous inspection the service was found to be in breach of legal requirements under good governance and staffing. Relating to the management of incidents and the culture within the service. At this assessment only minimal improvements were observed, and the service remained non-compliant with both regulations. At this assessment, minimal improvement was observed, and the service remained non-compliant with both regulations, risk management and 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.

Staff of all backgrounds did not always feel valued and respected. However, the service had a shared vision and strategy and was working to improve the culture.

Staff were passionate about their work and service provided for women; however, they highlighted that low staffing had impacted on staff morale and wellbeing. Staff told us although culture had improved since the last inspection, they were still on an improvement journey, as there were still some pockets of incivility, racism, bullying, harassment and microaggression in the service. Staff felt there was no equity in work allocation and told us that some midwives from an ethnic minority group got more work.

Staff did not always feel supported, respected and valued. Staff felt they did not always have the opportunity or feel safe to contribute to discussions about the service without fear of being punished.

The trust had many human resource (HR) maternity cases, particularly for the service. Between June 2024 and June 2025, the service reported 50 HR cases, of which 43 were on-going and related to 70 staff members. Senior staff told us there had been an increased number of HR cases in the last 12 months, which suggested staff were developing confidence to raise concerns. The increase in number of staff escalating issues to HR to seek resolution also raises a concern about the local leadership team ability to successfully resolving issues when they arise. Many concerns related to bullying and harassment (39%), disciplinary (30%), sickness absence and capability (14%), grievance (11%) and capability and performance (6%).

Following our last inspection, the trust had implemented some on-going cultural improvement projects aimed at addressing episodes of unacceptable behaviour and language, including racism and discrimination in the service. As part of this cultural work the trust had commissioned a maternity services culture project, beginning with a staff-wide questionnaire. The results reflected similar concerns to those identified during our last inspection, with 95% of respondents indicating they had witnessed disrespectful and or negative behaviour.

In March 2025, the trust shared the results of the questionnaire with staff and outlined several planned actions in response. These included co-producing an anti-racism charter, a civility charter and a code of conduct with staff, delivering civility workshops, increasing visibility of the leadership team, providing cultural competency training and re-launching the managing violence and aggression pathways. However, the trust did not provide an update on the progression of these actions.

The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. In 2024, the trust published a 5-year vision and strategy outlining its goals and the actions required to achieve them. The maternity service adopted this strategy as part of its commitment to delivering high-quality care. This strategy had been developed in collaboration with staff, patients, partners and the public from across the trust’s networks. The vision statement was THRIVE, which stood for: Teamwork, Honesty and Openness, Respect, Inclusivity, Valuing People and Excellence.

The vision and strategy were focused on sustainability of services and aligned to local plans within the wider health economy.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team.

The maternity service had 5 strategic pillars to achieve the vision which were: Equality, Diversity and Inclusion, maternity clinical pathway, listening to service user voice, staff wellbeing and workforce development, training and education.

Leaders were not always visible, inclusive, compassionate, open. They did not always embody the culture and values of their workforce and organisation. They did not understand and managed the priorities and issues the service faced. However, leaders had the skills, knowledge, experience and credibility to lead effectively.

Bedfordshire Hospitals NHS Foundation Trust had maternity services at the Luton and Dunstable Hospital and the sister site, Bedford Hospital. Leaders had the skills, knowledge and experience to perform their roles. The service had a defined leadership structure, both across sites and specific to individual hospital sites. The cross-site triumvirate consisted of the director of midwifery, general manager and clinical director of gynaecology and obstetrics who were also the safety champions for the service. The Luton and Dunstable Hospital site had a quadrumvirate that consisted of a head of midwifery, a senior service manager, a clinical lead for obstetrics and gynaecology and a neonatal lead. The service was supported by maternity safety champions and non-executive directors.

Leaders had the experience, skills and ability to run the service. However, staff did not always feel leadership was visible, accessible, compassionate and inclusive. Staff reported that some of the midwifery leaders were not consistently visible or approachable for women and staff, and that they were not always consulted before changes took place.

Leaders did not have a good understanding of the services they managed, or the priorities and issues the service faced. Staff raised concerns around lack of succession planning and leaders did not have a focus on improving staff wellbeing and retention.

Staff on the wards felt managers could be more supportive, and communication with staff needed to be improved. This was particularly around changes in the service and the antenatal ward. Staff felt feedback was delivered through a top-down approach and they felt unable to give feedback to managers and leaders.

Senior midwifery staff reported concerns of micromanagement and feeling undermined by leaders. Midwifery staff raised concerns around a lack of trust and a disconnect between senior midwives (band 6 and 7) and grade 8 staff and above.

There were clear lines of reporting from the site leadership team, through the quadrumvirate to the trust board. The site leadership team reported that the trust quadrumvirate were very involved and approachable. The site quadrumvirate had a good understanding of the service they managed and reported working well together. They held meetings every 2 months, and a review of the meeting minutes between December and April 2025 showed consistent attendance, with apologies recorded as necessary. The meetings covered key areas such as governance and compliance updates, workforce, quality improvement projects, research and audits and future planning.

The service also held meetings for perinatal safety champions. However, the Trust only provided meeting minutes for the April 2025 meeting, so the frequency of these meetings could not be confirmed.

The April meeting was well attended, with representation from midwifery, obstetrics, and neonatal teams, as well as the trust quadrumvirate and board-level safety champions. There was a standard agenda which included topics such as governance compliance, workforce, mandatory training, culture and patient experience.

People did not feel they could speak up and that their voice would be heard.

The service did not have an open culture where staff could raise concerns without fear. Not all staff felt comfortable to speak up and where concerns had been raised this had resulted in punishment or not led to action been taken. Staff did not always feel encouraged to raise concerns and promote the value of doing so. Staff felt their voices were not heard. Staff felt unable to raise concerns with managers. We were told of occasions where some midwives had been told not to speak up at some governance meetings and told to say the bare minimum. This was not an improvement since the last inspection.

According to the trust 2024 NHS maternity staff survey, there had been a decline in staff feeling secure to raise concerns about unsafe clinical practice, involved in deciding changes that affect work, making suggestions to improve work and feel trusted to do my job compared to the previous year. However, there was slight improvement in staff feeling the organisation would address any concerns raised and feeling safe to speak up about anything that concerns them in the organisation.

According to the 2024 NHS maternity staff survey, there had been a decline in the score under the heading “We each have a voice that counts”, compared to 2023 by 2.4% and the 2024 hospital average by 11.2%.

Women, relatives, and carers knew how to complain or raise concerns. Managers investigated complaints, identified themes and shared feedback with staff. However, there were delays in the investigation of complaints. There were limited evidence that learning from complaints were used to identify patient safety concerns and improve the service. Staff were unable to articulate any learning or improvement to the service following a complaint investigation.

Staff understood the duty of candour. However, there was a backlog in the completion of duty of candour process and the service has plans in place to address this. Therefore, we were not assured that staff were open and transparent and gave women and families a full explanation if and when things went wrong.

The service had a freedom to speak up (FTSU) guardian and staff were aware of how to access support. According to the 2024 NHS staff survey, 86% of staff were aware of the trust’s freedom to speak up guardians. Between 1 April 2024 and 31 March 2025, 118 cases were raised by staff in the Luton and Dunstable Hospital maternity service through the freedom to speak up guardian. The main concerns reported were inappropriate behaviours, bullying and harassment, favouritism and staff wellbeing. Recent data from the May 2025 FTSU report which have been shared with the trust board showed that between January to March 2025, 28 members of staff in the Luton and Dunstable Hospital maternity service raised concerns through the FTSU guardian and champions which mainly relate to allegations of unfair process and favouritism, staff personal safety concerns, poor behaviours of managers and colleagues and alleged unsafe clinical practice. These findings highlighted the ongoing need to continue to improve the culture within the service.

The service took part in the Care Quality Commission (CQC) maternity survey 2024. The service performed at about the same level as other trusts in 16 questions, somewhat worse than expected in 4 questions and worse than expected in 4 questions. The question the service performed worse than expected in were staff introductions, staff working together, respect and dignity and the opportunity to ask questions. The trust had developed an action plan in response to the findings which included but were not limited to, reinvigorating the ‘Hello my name is’ initiative, the introduction of cultural competency training and promotion of the birth reflection service.

Staff also had access to professional midwifery advocates (PMA). Staff reported the PMAs were very approachable and useful when they required support.

The service did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them. Not all staff felt valued and respected.

Leaders made reasonable adjustments to support staff with protected characteristics to carry out their roles well. However, not all staff felt respected, supported, and valued. Staff reported there were still some incidents of microaggression, bullying and lack of trust in the service. Staff felt some aspect of culture had improved since the last inspection such as the experience and removal of the title of the internationally recruited midwives for midwives that trained and qualified abroad. Leaders had an action plan in place to address bullying, discrimination and harassment at all levels and for all staff.

Staff and leaders we observed on site were broadly representative of the population of people using the service.

Leaders ensured there were ways to engage with and involve staff with protected equality characteristics. The trust had equality networks such as BAME network LGBTQ+ and allies’ network and the disabilities and allies staff network that staff were involved in.

The NHS staff survey 2024 included trust specific data on Workforce Race Equality Standards (WRES) and Workforce Disability Equality Standards (WDES). This data was representative of the Trust as a whole and not specific to maternity services. The finding showed 25% of white staff and 26% of staff from other ethnic groups had experienced harassment, bullying or abuse from staff in the last 12 months. 59% of white staff believed the organisation provided equal opportunities for career progression or promotion, while 50% of staff from other ethnic groups felt the same.

The trust developed an equality, diversity and inclusion (EDI) framework which was developed to support the trust being ‘inclusive by instinct’. The framework had people aims and patient aims. The people aims were; empowering leaders, building line manager confidence in EDI and empowering all staff. The patient aims were; continue to improve accessibility for patients and provide accessible information for all. They also had actions to help comply with the aims above, this included but was not limited to development of cultural awareness and competence, building on their anti-racism statement and development of an anti-racism charter.

The trust did not have effective systems for governance or accountability. Risks were not always managed in a timely way. They did not act on information about risk, performance and outcomes, or share this securely with others when appropriate. There were gaps in the governance structure

Leaders did not consistently ensure that effective governance arrangements were in place across the service. The service did not always provide timely service quality data submissions to partner organisations. The governance team included a cross-site head of governance, a cross-site quality compliance manager, a quality and safety lead midwife, a guidelines midwife, quality governance facilitator and a bereavement specialist midwife. Staff told us there were gaps in the governance structure that hindered their ability to deliver a safe and effective service. Kay vacancies included a band 3 administrative staff member, a band 7 safety midwife, a band 7 quality and safety lead nurse gynaecology and a band 6 clinical effectiveness lead. The shortage of governance staff was documented on the service’s risk register and rated as amber. However, senior staff told us there was an ongoing recruitment drive for these governance roles.

We identified a lack of robust governance systems and timely processes for assessing, monitoring and managing risks, incidents, complaints, duty of candour, policies, guidelines and mandatory submissions of the perinatal mortality review tool. This was due to insufficient governance staffing within maternity services. We observed and staff told us that the gaps in the governance structure impacted on the review and management of incidents and maternity policies and guidelines. The service did not have a dedicated obstetric sepsis and governance lead and staff reported lack of obstetric support for risk and governance.

This delayed appropriate input in the review and management of incidents and maternity policies and guidelines. The post of a band 8c head of governance and quality improvement had previously been vacant for an extended period according to staff and was appointed to in February 2025. Post assessment, as part of the factual accuracy process, the service told us the post of a band 8c head of governance and quality improvement manager was a newly created post and was not previously vacant. Staff told us there was lack of leadership support and oversight around governance particularly around guidelines and audits which was not seen as a priority till the recent appointment of the band 8C head of governance. This impacted on the completion of key governance process and patient safety. On our follow-up visit on 15 July, staff told us the trust had recruited a cross-site Perinatal Mortality Review Tool (PMRT) midwife the previous week who was due to start later in the year.

Not all staff at all levels were clear about their roles and accountabilities. Some of the governance staff had received no formal induction and training and were unclear about their roles. Staff told us they had been told by senior leaders that a new governance structure was been developed.

Staff did not consistently have access to current policies, guidelines and standard operating procedures (SOPs) to plan and deliver high quality care according to evidence-based practice and national guidance. This could increase the risk of inconsistent practices, and potentially compromise patient safety. During our assessment we identified several out-of-date policies, guidelines and standard operating procedures and escalated these concerns to the trust. We reviewed 41 maternity policies and guidelines whilst on site. On the 11 June 2025, we found 12 out of date policies and guidelines for the service and 15 out date maternity cross-site policies and guidance. Staff raised concerns that some guidelines were not in line with national guidelines such as those relating to fetal growth. In addition, we found 3 outdated cross-site and 14 outdated SOPs specific to Luton and Dunstable Hospital maternity services. These included monitoring in multiple pregnancy, born before arrival, maternity services training needs analysis, swab instrument and swab counts, safeguarding and maternity safety and board level safety champions.

The service reported arranging monthly policy review meetings with multidisciplinary team involvement to address the backlog of outdated policies through a sprint approach. However, during our follow-up visit 15 July; we found that only 2 of the 12 out of date policies and guidelines for the service had been updated in June 2025, while 5 other guidelines had been included in the upcoming August 2025 sprint.

Although the trust had acknowledged the issue and had introduced monthly sprint reviews to address it, we remained concerned about the delays in action and the lack of additional resources to support the timely review and approval of outstanding policies and guidelines. Furthermore, evidence showed there was poor attendance across the MDT at the sprint review meetings.

Staff told us that an MDT approach was not always followed in the reviewing and ratification of guidelines, policies and SOP’s. Staff told us author(s) of policies, guidelines and SOP’s were not always present at meetings or contactable. Therefore, we were not assured that all relevant documents were subject to the MDT scrutiny necessary for effective review and ratification.

Staff told us and we observed, that locating maternity related policies, guidelines and SOP’s on the intranet was challenging. Staff said they were unable to search the intranet using keywords or phrases and needed to need to know the exact title or reference code of the document. This was particularly difficult for students, temporary/locum, preceptors or new staff who may not be familiar with the naming convention or document structure.

At the time of our inspection, the maternity risk register indicated that the service had 29 open risks and 28 cross-site open risks. These included issues such as MDT staffing, ventilation, rodent infestation within the unit, record keeping and antenatal and newborn screening. However, these risks were not being addressed in a timely manner.

While the risk register contained key information such as a risk identification number, title, risk owner, description, the current rating and the date it was last reviewed, it did not identify what date each risk was added. Additionally, staff concerns did not always match those on the risk register; for example, issues related to staff wellbeing, lack of administrative support for the governance systems and processes were not consistently reflected. The risk register also did not include the backlogs of incidents, complaints and duty of candour.

The service submitted collated data to Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK) as required. The trust also produced a quarterly board report of PMRT data.

The trust was not compliant with 5 out of 10 safety actions set out in the clinical negligence scheme for trusts (CNST): maternity incentive scheme (MIS) year 6. The CNST 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. The trust did not provide any information on actions they plan to take to ensure compliance with year 7. This meant we could not be assured that the trust would be compliant with the safety actions for the upcoming year.

We were not assured leaders had implemented recommendations from reviews of deaths, incidents and complaints due to the backlogs of complaints, incidents, open actions and delays in PMRT reporting due to insufficient governance staffing.

The trust submitted data to the maternity services data set (MSDS). The MSDS is a comprehensive dataset that captures patient-level information from the booking appointment until discharge.

The service collected data and analysed it. The service had a maternity dashboard of performance which was accessible to senior managers and had set metrics the trust uses to monitor whether their clinical outcomes were in line with national targets. Key performance indicators were displayed for review and managers could see the sister location site for internal benchmarking and comparison. These metrics included massive obstetric haemorrhage, bookings before 10 weeks gestation, 3rd and 4th degree vaginal tears and stillbirth rates.

The service also submitted data to the local maternity and neonatal system (LMNS) dashboard. The LMNS dashboard had similar metrics to the local maternity dashboard and allowed the trust to benchmark themselves against other trusts within their LMNS and facilitate shared learning and drive improvements across the networks.

Managers were able to access information to support them within their management role. This included information on the performance of the service, staffing and patient care.

Managers and staff carried out a programme of repeated local audits to check improvement over time and improve quality and safety in the service. Local audits included but were not limited to hand hygiene, equipment and infection prevention and control audits.

There was a framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information was shared and discussed with staff. Information was in an accessible format, and was timely, accurate and identified areas for improvement.

The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The trust did not always work collaboratively with other trusts within the Local Maternity and Neonatal System (LMNS) and the integrated care board (ICB) to share learning from incidents and drive improvement in the maternity service in the region. The LMNS is a collaborative framework designed to enhance maternity and neonatal services. It serves as a platform for partnership between the service and key stakeholders within the Bedfordshire, Luton and Milton Keynes health (BLMK) and care partnership. The LMNS held a monthly forum where each trust was expected to share incidents, their outcomes and the resulting safety actions to support learning across the region. We received feedback that leaders were not always open and transparent and did not collaborate effectively with all relevant external stakeholders and agencies. Service leaders were reported to be defensive by stakeholders and not proactive to share incidents, their outcomes and safety actions to support learning in the region at these meetings.

However, staff and leaders engaged with people and communities and partners to share learning with each other that resulted in continuous improvements to the service. Leaders worked with the local Maternity Neonatal Voices Partnership (MNVP) to contribute to decisions about care in maternity services. The MNVP had contributed to the development of an action plan in response to the Care Quality Commission 2024 maternity survey results. Service leaders had built working relationships with the MNVP and encouraged them to attend maternity meetings. The MNVP were active and passionate about their role, had regular engagement activities with leaders and women to make a difference to services provided to women who accessed the service. The MNVP had regular meetings with the trust and had easy access to the senior leadership team to escalate any concerns promptly.

The MNVP engaged with women and public through listening events held at local libraries, social media and undertook regular 15 steps challenges which involved the MNVP chairs conducting walk arounds of the maternity unit using the NHS England’s 15 step toolkit. The MNVP chairs communicated directly with women during these walk arounds.

The MNVP had engaged with women about the decision and plans for the new maternity unit that was been built. The MNVP had been involved in co-development of action plans in response to women's experiences, held a diabetes engagement stand for women, attended health summits, were involved in research survey and attended governance meeting. They had also been involved in projects such as the perinatal improvement project (PIP) and the national institute for health research (NIHR) maternity disparities project. The MNVP held annual awards for staff and the maternity ward that had received the most positive feedback from service users. For example, in February 2025, a community midwife won the MNVP staff award for receiving most positive feedback from service users. Data provided by the trust showed that 9 of the MNVP members were nominated for the East of England perinatal award based on their ethnic communities’ workshop project. One of the MNVP members won the award on 20 March 2025 and was commended for their collaborative approach to working with local community groups including women from the most deprived area and their work on translation services.

The service was not currently enrolled in the maternity safety support programme (MSSP) but had received a diagnostic review in January 2025 and reported they had engaged well in the process.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. However, staff contributed to safe, effective practice and research.

Due to the ineffective governance and risk processes, incidents and complaints backlog, and poor action plan implementation and duty of candour processes, we were not assured the service embedded clear and consistent processes to support continuous learning and improvement across the organisation.

Staff had opportunities to participate in research, and leaders encouraged innovation and participation in research activities. At the time of our inspection the trust employed 1 whole time equivalent (WTE) research midwife and had plans to recruit an additional WTE research midwife. The trust was actively involved in research studies, including the digital imaging versus ophthalmology (DIvO) trial and the SNAP2, which was exploring improved blood pressure control in women following hypertensive pregnancies.

In addition, the trust made efforts to recognise and celebrate staff contributions. The trust participated in the diseases attacking the immune system (DAISY) award programme. DAISY is an international initiative that honours and celebrates the skilful, compassionate care nurses and midwives provide every day. The trust also ran the recognising outstanding support worker excellence (ROSE) awards, which recognises and celebrates outstanding support workers. Staff members could be nominated for these awards by colleagues or patients.

Staff participated in national audits relevant to the service and learned from them.

The infant feeding coordinator won the East of England maternity support worker perinatal award in March 2025.