James Paget 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 7 quality assessments. Maternity was part of the women’s and children’s services. The leadership for maternity included a multi-disciplinary quadrumvirate consisting of the head of midwifery, an obstetrics clinical lead, a neonatal clinical lead and an operations lead. They were supported by a managing director, clinical director, medical director, and director of operations.

The service had had a 5-year strategy to manage and improve the service that they shared with staff. Staff acknowledged the changes that had been made and felt the service was a more positive place to work. They were more involved in decision making.

Leaders had the experience, capability and integrity to ensure the services’ vision could be delivered. They were knowledgeable about issues and priorities for the quality of services and could access appropriate support and development in their role. Leaders told us they visited clinical areas as often as possible, staff confirmed this and said leaders were visible, approachable and supportive. The service had a Freedom to Speak Up guardian to improve how staff raised concerns confidentially.

There were clear governance, management and accountability arrangements. The service had improved their reporting of incidents to most external systems, although internal recording was not always the same. Staff understood their role and responsibilities. Managers accounted for the actions, behaviours and performance of staff. There were systems in place to manage current and future performance and risks to the quality of the service. Information was used effectively to monitor and improve the quality of care.

Leaders implemented relevant quality frameworks, recognised standards and best practices to improve equity in experience and outcomes for people using services and tackle known inequalities.

Staff and leaders had a good understanding of how to make improvement happen. There were processes in place to ensure that learning happens when things go wrong. The service had strong external relationships to support improvement and innovation. Staff and leaders engaged with external work, including research, to embed evidence-based practice.

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.

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

At our last inspection we identified concerns regarding the culture of the service. Staff we met on our assessment were welcoming, friendly and helpful. We observed staff working together as a team to provide care and to positively impact women’s experience. Most of the staff we spoke with were positive about the service and the changes that had been made. Maternity staff told us they had good working relationships with medical staff and felt more supported than previously. One staff member described some of the supportive changes the service had put in place, such as ‘civility saves lives’ training that was incorporated into multidisciplinary team (MDT) training, to provide psychological safety for all staff. An ‘Improve Well’ app was developed to enable staff to tell leaders how they feel.

Most staff of all levels felt increasingly involved in decision making, which was positively impacting staff morale and the culture within the service. One staff member told us, “I feel like I can speak to [senior leader] and they are open to listening and making change … [they’re] a complete change to previous heads of midwifery”. However, some staff felt changes were made by leadership without risk assessing how it would impact staff members wellbeing and workload in the community.

The service had professional midwifery advocates (PMA’s) which is a role to help maternity staff by supporting their practice, wellbeing and professional development. The services offered by PMA’s included but was not limited to supporting maternity staff, providing a safe space to talk and be listened to, offering debrief sessions after clinical incidents and wellbeing and career development conversations.

The service had a 5-year vision and strategy, published in 2023 for what it wanted to achieve and objectives to turn it into action. The vision was “to provide a safe and exemplary maternity service” where people are “at the centre of how we plan and provide care”. The maternity and neonatal strategy was aligned to 4 priorities:

• Ensure that standards, structures and processes are in place to deliver safe, personalised and equitable care.
• Grow, retain and develop our workforce in line with the needs of the service.
• Work with service users, staff and community voices to shape our services.
• Create a collaborative culture of safety, learning and support through effective leadership.

This vision and strategy was adopted by the maternity service with an overview of each priority. The service planned to deliver their strategy through completion and compliance with national initiatives, such as the clinical negligence scheme for trusts (CNST): maternity incentive scheme (MIS), which it had complied with. However, the service did not provide details regarding how specific actions were going to be achieved. Information provided following this assessment told us 92 of the 94 actions had been completed. We were assured through other information obtained during our onsite visit that appropriate action was being taken to complete the 2 remaining actions.

Leaders at all levels had the skills, knowledge, experience and credibility to lead effectively and staff felt leaders were compassionate.

The service had a history of unstable leadership, which had impacted on staff morale and resulted in us taking enforcement action at our last inspection. However, at this assessment, we found the trust had made changes and the service now had a fully established leadership team.

Maternity services sat within the women’s and children’s services and had a trust level perinatal leadership team also known as the quadrumvirate. The quadrumvirate consisted of the head of midwifery, obstetric clinical lead, the associate director of maternity improvement, the neonatal unit clinical lead and head of the neonatal unit and children and young persons services. They were supported by a range of other staff, including a consultant midwife, along with other specialist and lead midwives and matrons.

Leaders had the experience, skills and ability to run the service. There had been a major change in service leadership since our last inspection, which resulted in a complete changeover of senior staff. Staff told us senior leaders were approachable and the head of midwifery was “very visible”. Two members of staff commented they had seen them on units to support staff when staffing had been low and to resolve an equipment problem. Another staff member said, “leadership is very visible, had them check in with her, everyone has been really welcoming. It seems like all leaders have open doors, it’s a very visible team compared to where I have been - no one has been hidden or unapproachable.”

However, staff did not always feel leaders consulted with them about changes within the service. Staff reported that changes within the continuity of care teams in the community had negatively impacted the care they were able to provide. This included taking staff from community resources but failing to provide staff when community teams were short. Staff told us this made them feel they were not getting support from leadership.

The service held weekly divisional leadership meetings but did not provide meeting minutes to us. We reviewed the agendas and action logs for 3 meetings in September 2025 but could not determine whether the meetings were well attended or not. The meetings covered key topics such as divisional risks, quality and safety, including patient harm and complaints, and operational aspects.

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

The service had maternity board safety champions, including a non-executive director who took on the leadership role for maternity 3 years ago. The role of a board safety champion is to provide proactive board level leadership and bridge the gap between the service and the board. They reported doing regular walk arounds, alternating between each hospital site. They collated information from staff and women and produced a poster highlighting what has been done in response to what was raised. All the service’s safety champions met monthly to discuss issues, such as complaints, actions and learning. They reported to the trust board each month and told us maternity presented their own update and the support of board safety champions increased the profile of maternity services.

There were clear lines of reporting from the site leadership team, the quadrumvirate and the board. The service held monthly maternity and neonatal meetings which was also chaired by the director of midwifery (executive board safety champion). The meetings covered key topics, such as updates on improvement , compliance with national schemes, women’s experience and local, national and regional updates. We reviewed the meeting minutes for August 2025 and found the meeting was made up a multidisciplinary team and the quorate.

The service provided a freedom to speak up service and staff felt they could speak up.

The trust’s guardian service was introduced in May 2024 in response to a staff survey that highlighted a need to improve staff confidence in raising concerns and that actions would be taken. The service had a freedom to speak up (FTSU) guardian and staff knew how to access them and we observed posters with the FTSU guardian details. Staff had raised 5 concerns to the FTSU guardian between January 2025 and October 2025. These concerns were related to processes, behaviour or relationships, management and bullying or harassment. There were no repeat themes, although service leaders recognised the potential area for further review in the management concerns raised.

Staff also had access to professional midwifery advocates (PMA) and management at all levels. The service also held staff meetings in individual areas within the service this included community, maternity wards and labour ward. The service also had separate meetings for students, safety and flow midwives and band 7 midwives. Staff were able to attend these meetings in person and virtually.

Most staff felt valued and respected. However, there was a discrepancy between different staff groups regarding bullying and employment prospectives.

Staff and leaders, we observed onsite, were representative of the population of people using the service. Staff we spoke with felt valued and respected by other staff and reported having positive working relationships. We also observed positive multidisciplinary working onsite.

The trust’s workforce race and disability equality standard data for 2024 showed there were more black and minority ethnic staff at band 5 level due to international recruitment. However, this had not translated to higher positions, which meant black and minority ethnic staff were not represented across the whole organisation. This data is representative of the trust as a whole and not specific to maternity services.

The finding showed fewer white staff experienced harassment, bullying or abuse from staff than staff from other ethnic groups in 2022 and 2023. There was also a greater divide between these numbers in 2023 than in 2022. Similarly, fewer white staff experienced harassment, bullying or abuse from women, relatives or the public than staff from other ethnic groups. However, both the percentage of staff reporting this and the divide between the staff groups had reduced in 2023 compared with 2022. All of these figures were above the NHS average. Findings from the hospital workforce disability equality standards question showed 54% of staff with long-term conditions or illnesses and 52% of staff without long-term conditions or illnesses reported they had experienced harassment, bullying or abuse from other colleagues, managers or women in 2023.

Only 55% of white staff and 47% of staff from other ethnic groups believed that the organisation provided equal opportunities for career progression or promotion. Fifty percent of staff with long-term conditions or illnesses and 55% of staff without long-term conditions or illnesses believed that the organisation provided equal opportunities for career progression or promotion.

The trust had completed an NHS equality delivery system improvement tool to review and develop their approach in addressing health inequalities, including in the trust workforce. This looked at staff with long term conditions, abuse, harassment and bullying, and staff access to support.

Maternity leaders operated governance processes, throughout the service and with partner organisations, although not all incidents were recorded in all required monitoring systems.

At our last inspection we identified concerns regarding under reporting incidents to the maternity dashboard. At this assessment we found that data for post partum haemorrhages were submitted to the maternity dashboard and all but one report was also found on the learn from patient safety events (LFPSE) service. Similarly, the percentage of shoulder dystocia was greater on the maternity dashboard than the 2 reports on LFPSE suggested. This provided comparison with other similar sized services and allowed the local maternity systems track, benchmark and improve services. However, having differing information on LFPSE risked not having local reference points to easily learn from incidents.

The service showed evidence of submitting 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 MNSI then investigated and where relevant safety recommendations are made. The service had made 1 referral to MNSI in the previous 12 months before our visit. Twelve recommendations were made, including for CTG, MDT communication and neonatal resuscitation training, reviews of the emergency call system, CTG categorisation, and the process for reassessment of changing risk factors antenatally. The report also recommended work to improve staff communication through freedom to speak up, and communicate with other colleagues in emergency events or when handing over clinical information. Staff completed a national perinatal mortality review tool following this incident, which identified some, but not all, of the same issues as the MNSI report. We saw through looking at records during our assessment, information provided by the service and speaking with staff, there had been improvements in these areas.

Data submitted by the service showed that they held monthly multidisciplinary perinatal mortality review tool (PMRT) meetings and used the tool to review care and report on deaths occurring within the service. Collated data was submitted to Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK) in line with national requirements. The trust also produced a quarterly board report of PMRT data.

Staff at all levels were clear about their roles and accountabilities, and they had regular opportunities to meet, reflect on and learn from the service’s performance. The service held monthly governance committee meetings attended by multidisciplinary staff. We reviewed the minutes of the meetings held between January and March 2025 and found them to be well attended and comprehensive. Each meeting had a set agenda, which included but was not limited to service productivity/performance, committee reports, and approval of standard operating procedures (SOPs) and guidelines.

The governance team was made up of the service’s quadrumvirate members and other senior staff, such as lead midwifes and patient safety managers. Leadership staff maintained a risk register to monitor the service’s most significant risks and they were able to confirm the top risks for the service. These included continuity of care service, recruitment to the maternity diabetic team, the service’s governance processes, staffing and culture. Leaders met monthly to review these risks and escalated them to the trust board through the divisional risk oversight group and divisional governance meetings.

The trust monitored incidents and had a clear process for incident investigation. Managers told us they routinely reviewed incidents submitted by staff through the incident reporting system, assessing both the detail and the level of harm. Managers then investigated incidents to determine whether they could be closed and used for learning or whether they should be escalated to the weekly patient safety incident response framework (PSIRF) panel. The panel decided whether a patient safety incident investigation (PSII) was required and/or if the case should be referred to the maternity and newborn safety investigation (MNSI) programme.

The service reported that all PSII reports were presented to the patient safety executive review group (PSERG) for approval of the findings and recommendations. When PSIRF was introduced in September 2023, the service had a backlog of PSII investigations. To address this, the trust recruited additional staff to the investigator role and involved maternity staff in the process. As a result, 2 of the 4 outstanding reports had been completed at the time of our visit and the remaining 2 scheduled for completion the following month.

The service collected reliable data and analysed it. 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 dashboard included monthly metrics on key performance indicators (KPIs) which included but was not limited to the number of births, types of birth, episiotomies, stillbirth and postpartum haemorrhages. The service had targets for some of the KPIs, which they met except for smoking at the time of delivery. Maternity leaders were aware of this and were taking actions to improve performance in this area.

The LMNS dashboard contained KPI data relating to all NHS trusts within a LMNS, this could then be used by managers for internal and external benchmarking and comparison. The service submitted data to and attended the LMNS meetings to enable all services within the LMNS to present perinatal mortality data, incidents and service user feedback, which facilitated system-wide learning.

Managers and staff undertook a comprehensive programme of repeated local audits to monitor progress and drive improvement over time. These audits included but were not limited to induction of labour, diabetes, hypertension and postnatal sepsis.

The trust was compliant with the clinical negligence scheme for trusts (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.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people.

Staff and leaders were open and transparent, and they worked collaboratively with relevant external stakeholders and agencies. The MNVP chair had been in the role for over 4 years and reported being actively involved with the service. They described having an open and positive working relationship with the service’s leadership team. The MNVP chair regularly attended a variety of meetings with maternity leaders, who reported that they knew her well and were able to discuss issues openly. The meeting agendas we reviewed demonstrated that these meetings covered a range of maternity topics and issues, and were well attended by representatives from the leadership team. Staff developed a quarterly action plan following these meetings to track and ensure the correct work was carried out to improve the service.

The service provided us with a list of listening events, surveys and co-produced completed by the MNVP in the 18 months prior to our visit. These showed the development of training films and care booklets, in response to concerns and areas for improvement that had been identified at the listening events and in surveys.

The service also worked closely with the local maternity and neonatal system (LMNS), who supported the maternity leaders to look critically at the service, identify what they were doing well and what needed improvement. This was done through the Sixty Supportive Steps to Safety framework, with the most recent version (v3) being completed in April 2025. The LMNS shared the outcome of their visit with other stakeholders and agencies, who had roles in supporting the service with improvement and share good practice with other services.

Senior leaders told us support in their improvement journey following our last inspection came from regional midwifery leaders, the Deanery (regional bodies responsible for managing medical training) and NHS England's maternity safety support programme.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff actively contribute to safe, effective practice and research.

Leaders encouraged innovation and participation in research. The maternity service was participating in 7 research studies, with 3 that had been completed or closed and 4 still ongoing. These were a combination of multi-centre, national trials, trials developed by individual staff members or in collaboration with education establishments.

Staff and leaders engaged with external partners, including research networks, to help embed evidence-based practice. The service collaborated with regional organisations, such as the Integrated Care Board and Local Maternity & Neonatal System, where these organisations supported research ideas.

Leaders encouraged continuous learning through quality improvement initiatives. Ongoing improvement work was in place across the maternity and neonatal departments, driven by a focus on patient safety. This included the development of new training for midwives, such as perineal repair, which had been introduced in response to staff feedback, learning from incidents and audits.

Maternity leaders collaborated with the MNVP to promote research to women who expressed interested in taking part. The MNVP were also actively involved in quality improvement work, gathering feedback through conversations and surveys with women on specific subjects, such as neurodiversity. They then contributed to the development of staff training aimed at improving understanding and enhancing the quality of care for women.

Staff were supported to attend and present at conferences and to contribute to work with disadvantaged communities. The service provided evidence of midwifery staff delivering emergency skills training to healthcare workers in Sierra Leone. Two registrars gave presentations at a Royal College of Obstetrics and Gynaecology conference in Egypt to support local staff knowledge and learning.

Student midwives were supported by a clinical educator, who developed daily support sessions for hospital-based students and fortnightly sessions for those working in the community. They also provided a monthly education update designed to help students meet their learning objectives and strengthen their clinical knowledge, incorporating suggestions from the students. For example, when students highlighted a need for improved understanding of bereavement care, a dedicated study session was created that met their expectations and enabled them to achieve their required proficiencies.

As a result of this work, the clinical educator team was recognised at the East of England Perinatal Awards for their outstanding contribution to student education and support.