Queen's 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

As this was a focussed assessment, we only assessed the ‘shared direction and culture’, ‘capable, compassionate and inclusive leaders’ and ‘governance, management and sustainability’ quality statements. We looked for evidence that there was an inclusive and positive culture. We checked that leaders proactively supported staff and delivered care that was safe, integrated and sustainable. We have combined the scores from these 3 areas with scores from the previous assessment.

At the previous assessment the service was in breach of good governance, due to weakness of governance processes and risk management. Since then, the service had made improvements and is no longer in breach of this regulation. This is because the service now had improved governance processes, leaders were aware of key risks within the service and took appropriate actions to manage and mitigate risks. As a result, the rating for this area improved to good.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a clear shared vision, strategy and was working to improve the culture.

The trust had a purpose statement and values, and staff we spoke with were aware of them. The trust purpose was ‘We want our hospitals to deliver care our staff are proud of and our patients are happy with’. The values were PRIDE, which stood for:

• Passion
• Responsibility
• Innovation
• Drive
• Empowerment

Maternity services had a 5-year strategy, published in 2025, which outlined the service’s vision for safe, personalised, equitable, and responsive maternity care for every woman, birthing person, baby and family. The strategy had 7 priorities the service wanted to focus on. These were;

• Safer Maternity Care: Building Resilience through Learning, Openness, and Accountability
• Personalised Care: Respecting Choice and Empowering Informed Decisions
• Continuity of Carer: Strengthening Relationships, Transforming Outcomes
• Improving Mental Health and Postnatal Support
• Listening and Responding to Women, Families, and Staff
• Investing in Our Workforce and Ensuring Safe Staffing
• Electronic Patient Record (EPR): Optimising Data and Digital Tools

Staff we met were welcoming, friendly, and helpful. We observed staff working together as a team to provide high quality care and to positively impact women’s experience. Most of the staff we spoke with were positive about the service. However, a few staff reported the culture within the service was not always positive, with isolated incidents of incivility between colleagues. Leaders reported being aware of how poor morale and culture within the service could affect the quality of women’s care. To understand the culture within the service, a SCORE survey was commissioned in 2024, which is an internationally recognised way of measuring and understanding organisational and teams’ culture. Leaders reported ongoing work to improve the culture. It included development of a shadow quadrumvirate, which involved a group of staff from bands 2 to 6 and junior doctors, giving senior leadership within the service a greater understanding of the impact of their decisions on colleagues. The service also reported organising listening events and created space for more open discussions with staff about how to address poor behaviour.

The service was also working to address inequalities towards staff and women. The service created an equality, diversity and inclusion improvement plan which covered topics on recruitment, pay, health inequalities, internationally recruited staff and bullying, discrimination, harassment and physical violence.

Leaders had the skills, knowledge, experience, and credibility to lead effectively. They did so with integrity, openness, and honesty.

Maternity services were part of the Women’s and Children’s Division. At trust level, leadership was provided by the quadrumvirate. The quadrumvirate was comprised of the clinical group director for women and children, the clinical group director of midwifery, the clinical group director of nursing, and the clinical director of operations. It also had a team, defined as triumvirate, which was responsible for the operational delivery. The triumvirate consisted of the clinical director for women’s health, the head of midwifery, and the general manager for women’s health. The service also had board safety champions and frontline safety champions.

Leaders, including the chief executive office and chief nurse, had the skills, knowledge and experience to perform their roles and demonstrated good understanding of the services they managed. They were aware of the risks within the service and were able to describe the mitigations and action plans in place. Leaders reported having enhanced access to the board and described recent financial investment that had supported improvements in maternity services since the previous assessment.

Staff told us leaders were visible in the service and approachable. There were clear lines of reporting from the site leadership team through to the quadrumvirate and the board.

Leaders understood the needs of the local population, including how health inequalities affected treatment and outcomes for women, babies and families from ethnic minorities and disadvantaged groups. They worked closely with various stakeholders such as the maternity and neonatal voices partnership (MNVP) and the local maternity and neonatal system (LMNS). They also attended various meetings and had an extensive programme to improve the equity of experience and outcomes.

Leadership development opportunities were available for staff at all levels. This included the introduction of the shadow quadrumvirate to support staff development and enhanced management training for band 7’s and above. Senior midwifery staff were also supported to attend an inclusive leadership programme, which aimed to address both clinical excellence and cultural competence.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality care, treatment. and support.

Leaders operated effective governance processes, throughout the service and with partner organisations. The governance team was made up of a lead for patient safety quality assurance and governance for women’s health, a quality and safety risk manager, a quality improvement and assurance midwife, a clinical midwifery project lead and a lead midwife for safety.

Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service. The trust held monthly perinatal governance meetings, chaired by the director of midwifery and attended by multidisciplinary staff. We reviewed the meeting minutes from May to July 2025 and found the meetings were well attended and comprehensive. Standing agenda items included incidents and learning, perinatal mortality, the risk register, external audits and submissions, safeguarding, clinical guidelines and patient experience.

Staff we spoke with were aware of the risks within the service. The service had a risk register that had 21 open risks recorded at the time of the assessment. The register included the date the risk was added, a description, the score, cause and impact, the allocated owner, the review date and the controls in place. The risk register included the risks we identified during the assessment, which provided assurance that leaders and staff were aware of the risks within the service.

Data and notifications were submitted to external organisations. The service submitted all qualifying cases to the maternity and newborn safety investigations (MNSI) programme. 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 trust had referred 2 cases to the MNSI in the last 6 months, 1 of which was rejected.

The service held monthly multidisciplinary perinatal mortality review tool (PMRT) meetings and used the perinatal mortality review tool to review care and 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. The trust also produced a quarterly board report of PMRT data. The MBRRACE- UK 2023 perinatal mortality report showed that the service was an outlier for neonatal mortality rates. In response to this the service reported ongoing work to reduce stillbirths and neonatal death. Perinatal data supplied by the service for June and July 2025 showed the service met national targets for perinatal mortality.

The service collected and analysed reliable data. The trust submitted data to the maternity services data set (MSDS). The MSDS is a national dataset that captures patient-level information from the booking appointment until discharge.

The service had a local maternity performance dashboard, which was developed to monitor performance and strengthen oversight. The performance metrics included workforce fill rates, theatre utilisation and delays in clinical activity such as medical reviews in triage, induction of labour and discharges.

The service also submitted data to the local maternity and neonatal system (LMNS) dashboard. This dashboard contained KPI data from all trusts within the LMNS and was used by managers for internal and external benchmarking and comparison. It included the number of bookings, number of births, types of birth, stillbirths and postpartum haemorrhages. The service had targets for some of the KPI’s and generally met them between April and July 2025.

The trust was compliant with the clinical negligence scheme for trust (CNST): maternity incentive scheme (MIS) year 6. 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. At the time of the assessment the service was working towards compliance for year 7.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.