Milton Keynes 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 rated Well-led as requires improvement. We assessed 6 quality statements on leadership and governance. Maternity was within the women’s and children’s services at Milton Keynes university hospital. Since our last inspection the leadership team had changed which meant some roles had yet to be embedded.

Staff we spoke with reported managers and most matrons were visible and approachable.

Leaders were able to identify the top risks on the risk register and of their mitigations. There was a strategy alongside a set of values and a leadership “quad team” oversaw the maternity department. Leaders completed various leadership courses and there was a Freedom to Speak up team within the trust.

Senior leaders and staff had a good understanding of quality improvement projects and provided positive examples of when they were encouraged to contribute to improvement initiatives.

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.

Prior to the assessment a small number of anonymous whistleblowing escalated concern regarding a poor culture within maternity. We conducted a responsive staff survey and ran staff focus groups with different grades of maternity staff.

In total 76 staff responded to the survey, just over half of respondents agreed that the organisation acted fairly towards staff, regardless of their ethnic background, gender, religion, sexual orientation, disability or age (57% strongly agreed or agreed), nearly a third neither agreed nor disagreed, and only a few respondents disagreed (13% disagreed or strongly disagreed). Responses to questions around raising concerns and speaking up were mixed. Almost half of respondents felt confident raising concerns through the Freedom To Speak Up process (45% strongly agreed or agreed). However, nearly 40% neither agreed nor disagreed. Nearly two thirds agreed they were confident that their line manager would take action to address concerns (63% strongly agreed or agreed). Although nearly two thirds agreed that they felt safe to report concerns, this question had the highest proportion of disagreement across all survey questions, with almost a third not feeling safe (32% disagreed or strongly disagreed).

Most staff we spoke with were proud of the organisation as a place to work and there was a mixed response at all levels about the culture. Some staff across the maternity unit felt they were not always supported, safe, respected, and valued within the wider organisation – and some had experienced incidents of incivility. During the assessment we saw that staff were not able to take breaks as there would not be sufficient oversight of the ward. We were also told about tense working relationships on the labour ward during periods of high patient acuity. Following the inspection the trust responded to confirm there is an internal process for the monitoring of breaks - the break sheets didn’t identify any staff who didn’t get a break.

We discussed these concerns with senior leaders within the maternity service. Leaders told us they were aware of some concerns and were working with staff to understand staff experience. 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. The service had a plan of actions as a result of the feedback sessions that included improving communications, a monthly newsletter, leadership training, 360 degree appraisal for senior leaders and interactive freedom to speak up (FTSU) sessions.

Staff understood how to raise concerns, and most told us what they would do. Staff we spoke with described they could raise concerns with their line manager and divisional leads but not the executive team. There were cohorts of maternity staff said they were not always confident in speaking up. In response, leaders within the maternity service had engaged with staff who were actively encouraged to speak up and raise concerns.

The service had a maternity strategy 2021-2025 and the new leadership team were working to communicate their vision to develop the maternity service.

Staff understood how to raise concerns, and most told us what they would do. Staff we spoke with described they could raise concerns with their line manager and divisional leads but not the executive team. However, there were cohorts of staff within maternity that said they were not always confident in speaking up. In response to this leaders within the maternity service had engaged with staff who were actively encouraged to speak up and raise concerns.

Staff told us that leaders were visible and most felt respected, supported and valued. Staff told us that there were regular safety visits and visibility from the board safety champions. Some staff were not assured that board safety champions fully appreciated workforce challenges.

Most staff told us they had good working relationships with their ward managers who they described as approachable and visible. Leaders of the service were able to describe the challenges the service faced in relation to the estates, capacity and acuity, improving culture and responding to themes from patient feedback. There had been ongoing recruitment challenges to recruit to a women's health clinical governance and QI lead.

All staff we spoke with were able to provide the top risks to the service. For example, the importance of triaging women quickly when they enter the service, issues with the estates and staffing pressures. Senior leaders could articulate the mitigating plans to address these risks.

Since our last inspection there had been significant changes within the maternity service leadership structure. The divisional chief midwife and deputy midwife roles had not been in post at the last inspection. The service also had 3 matrons to support inpatient, outpatient and labour ward and triage areas.

The service had leaders who understood the context in which they delivered care and treatment. Leaders had developed an action plan in response to concerns about workforce culture. The quadrumvirate leadership team attended the national leadership training programme.

The leadership team were engaging with local community groups and the MNVP to understand the needs of the local population. Most leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff we spoke with were aware of Freedom to Speak Up (FTSU) at a trust level but were not always sure who their local champions were. At the time of the inspection the FTSU guardian was new in post.

Whilst most staff felt able to speak up some staff told us they did not always feel safe to report incidents or have confidence in the freedom to speak up process due to fear of reprisal and concerns around lack of confidentiality.

Leaders had conducted staff led listening events to understand workforce concerns within maternity and were working to develop action plans to improve the culture.

There were 3 routes to report a concern to the Freedom to Speak Up (FTSU) guardian. To protect anonymity staff could scan QR codes to raise concerns Most contact was through direct contact with the FTSU guardian. These were regularly reviewed by the quadrumvirate leadership team.

The maternity and neonatal safety champions at Milton Keynes are the Chief Medical Officer a Non-Executive Director and the Divisional Chief Midwife. All of whom attend the Maternity Assurance Group (MAG) to fulfil the role of safety champion.

The trust had a freedom to speak up policy.

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.

We spoke with staff from a range of backgrounds who told us they felt valued and equal members of the team. However, some staff shared their experiences of leadership and organisational culture within the Maternity Unit, which highlighted some concern that a poor culture was developing. CQC conducted a responsive staff survey and 76 staff responded. It found that half of staff agreed that the organisation acted fairly towards staff (regardless of ethnic background, gender, religion, sexual orientation, disability or age), and there were some reports that people felt there had been unfair treatment and discrimination based on protected characteristics.

We conducted a responsive staff survey and ran staff focus groups with different grades of maternity staff.

Just over half of respondents agreed that the organisation acted fairly towards staff, regardless of their ethnic background, gender, religion, sexual orientation, disability or age (57% strongly agreed or agreed), nearly a third neither agreed nor disagreed, and only a few respondents disagreed (13% disagreed or strongly disagreed).

Leaders demonstrated an understanding of the Workforce Disability Equality Standard (WDES) and Workforce Race Equality Standard (WRES) and were well-informed on the organisation’s performance against these.

There was support in place for internationally educated midwives that was linked to the equality, diversity and inclusion (EDI) strategy.

There were a wide range of staff networks and support available to meet the needs of diverse staff groups within the trust. Equality, diversity and inclusion training was completed as part of the core training required of all staff.

The service recognised the work of internationally educated midwives within the service and participated in recognising shared values on international day of midwives.

Staff we spoke with understood the governance structure and understood where to find specific policies.

Staff said that team meetings did not always happen and that key messages were distributed by email and staff did not always read these. Following the inspection the trust stated that team meetings are only cancelled due to clinical acuity. This is supported in the Maternity Escalation Plan. Key messages to the team are cascaded through a variety of mediums including, meetings, team huddles, newsletters and emails.

There was a weekly quadrumvirate that went through a standardised agenda and updated a rolling action log. The Non-Executive Director (NED) met with the senior maternity safety champions and neonatal leaders to discuss the maternity assurance group agenda and attended the safety champions meeting.

The service had a formalised governance framework and processes to support the safe and effective delivery of care.

Senior leaders were sighted on the plans and continued to address known risks. Risks were tracked and monitored through the maternity services governance process. The service had a risk register that had 18 open risks. The risk register included a reference, description of risk, risk owner, review date risk rating score. Most risks included risks that we found on inspection although there was not a specific risk about fire safety issues.

There was a process to investigate clinical incidents and refer cases to the Healthcare Safety Investigation Branch (HSIB) and NHS Resolution’s Early Notification Scheme.

Key staff took part in a quarterly perinatal mortality review tool (PMRT) meeting, which were held regularly as part of the Clinical Negligence Scheme for Trusts (CNST) these meetings were used to monitor the performance of the trust and identity any learning opportunities where improvements could be made and additionally monitored outcomes by ethnicity and deprivation.

There was clear reporting from maternity services to the trust board – this included updates from the maternity assurance group about staffing and themes from incidents.

The governance team was not yet fully established and functioning, the team was working to cover a vacancy and delays in incidents being actioned and closed promptly.

Managers and staff carried out a comprehensive programme of regular audits to check improvement over time. They audited performance and identified where improvements were needed.

On inspection we raised concerns regarding the estate that was used for delivering maternity services. We observed some equipment was being stored on a maternity ward that would have obstructed the movement of a patient in an emergency and bulky equipment would have needed to be moved out of the way for a trolley to pass. This equipment was removed on the second day of our inspection, however there was a concern that leaders did not appreciate the risk to women and birthing people when these concerns were fed back.

We reviewed the minutes of the Maternity Assurance Group (MAG) meeting. The minutes showed good attendance by different levels of staff within the maternity service and provided an overview of the service and a review of risk.

The Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. 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. Staff reported that the service had responded well to MNSI recommendations highlighted in an MNSI report especially in relation to improvement in triage. This was reflected in the risk register.

Managers shared and made sure staff understood information from the audits

The service had 11 policies that were out of date when the service was inspected. These policies included ‘thromboembolic disease in pregnancy’ that was due for review in April 2023, ‘women with disabilities and special needs guideline’ that was due for review in June 2023, substance misuse in pregnancy that was due for review in May 2023’. The service had an action plan to review the overdue documents.

The service worked with the local maternity voices partnership (MVP) to ensure the voices of women and birthing people were heard. The MVP reported that women and birthing people had a broad range of both positive and negative experiences at the service. They consistently received complimentary reflections about the support provided by the perinatal team. There were consistent themes being communicated by women and birthing people regarding delays in induction of labour, wait times and informed consent. There were regular meetings between staff and the MVP to collaborate on a range of activities such as reviewing complaints and guidelines.

We reviewed the minutes and agendas for the maternity service user experience review groups for January, February and April 2024. The meetings covered Quality Improvement Project/ Plan (QIPP) within maternity, themes from birth reflections meetings between mothers and staff, the maternity service user experience report, patient experience reports, MVP updates, ward and neonatal unit updates. The meetings were well attended by a multidisciplinary team.

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.

Leaders and staff had a good understanding of Quality Improvement (QI) methods and the skills to implement these improvements. Most of the projects had yet to be embedded into practice to demonstrate improve patient outcomes. The metrics used to assess the induction of labour showed variable results.

Some staff said that when incidents were reported learning was not always shared with maternity staff.

During the assessment all staff we spoke with demonstrated a commitment to continued professional development.

The maternity service had a number of quality improvement projects in place these included improving post natal discharge, avoiding admissions to the neonatal unit, improving maternity documentation and improving translation services.Staff contributed to programmes, such as the patient safety incident response framework (PSIRF) and multidisciplinary review meetings, that provided reflection and learning. Staff and leaders engaged with external work, including research, to embed evidence-based practice.