Musgrove Park 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 the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of regulation for good 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.

We scored the service as 2. The evidence showed some shortfalls. The service did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The service had an improvement plan but not a maternity specific strategy. Leaders told us they had been concentrating on immediate risks and improving maternity care. They spoke passionately about the improvements they wanted to achieve and strategic aims for the service, however it was unclear for all staff. The service improvement plan contained 10 components. The aim of the plan was to create safer care by focusing on workforce, estates, governance, positive safety culture and reducing health disparities. The service was keeping track of progress against these metrics.

Staff morale was divided. Some staff reported feeling uncertain about the service’s direction, particularly with the reopening of Yeovil maternity unit and forthcoming staff consultations. Not all staff felt there had been support available and that their concerns were listened to. Others welcomed the changes being implemented and viewed them as positive improvements. Most staff felt the service they provided to women had improved with the additional external support provided and actions taken. Overall, there were mixed perceptions of the culture, with concerns about changes and workload. This variation in morale and confidence had the potential to impact staff engagement and the consistency of care delivery.

Leaders acknowledged the action plan around culture had been delayed due to operational demands and the short notice temporary closure of Yeovil maternity unit. We reviewed the culture action plan which had been informed by the staff survey and feedback from complaints and PALS. Out of the 36 action points, 17 had been completed. Senior leaders of the service were undergoing a course to support improvement and culture and we were told this work would continue once Yeovil maternity unit reopened. Staff spoke about periods of relentless challenge and the short notice temporary closure of the Yeovil maternity unit.

Feeback from midwifery staff surveys demonstrated staff were below the comparator in the majority of questions relating to their job, managers and personal development. The service told us support had been provided to matrons focussing on higher sickness and concerns around wellbeing in the context of significant service change. Sessions were held with the team to discuss how to effectively manage supporting attendance and improve wellbeing.

Senior leaders visited wards, there were 6 monthly staff forums and a regular newsletter for staff. However, some staff reported leaders visited wards and heard concerns, but this was not meaningful as things did not change. Some staff said they did not have time to read newsletters.

The service worked alongside the Local Maternity and Neonatal System (LMNS), Maternity and Neonatal Voices Partnership (MNVP) and Maternity and Newborn Safety Investigations (MNSI) programme in addition to other services to better respond to the needs of the local population.

We scored the service as 2. The evidence showed some shortfalls. Not all leaders understood the context in which the service delivered care, treatment and support. Leaders were being supported to develop their skills and knowledge to lead effectively.

There was a clear leadership structure for maternity services. Leaders recognised the maternity service had been under considerable public scrutiny in recent years and they had supported staff with compassion. The Midwifery senior leadership team led the maternity unit, which was part of the Women’s and Children’s services. This included a Director of Midwifery, Associate Medical Director, Associate Director of Neonatal and Maternity Services and a Service Director (for the Children and Young People and Families Service Group). A Non-Executive Director held responsibility for maternity. Due to issues identified at the previous inspection and an inadequate rating, the Director of Nursing and other senior leaders were supporting the divisional leaders to drive improvements. Leaders spoke positively about the oversight and support provided at executive level and felt challenges were understood.

There had been recent changes to the services leadership structure at Head of Midwifery and Matron level. Inpatient services remained site specific, but services including community, outpatients, triage and infant feeding had become cross site. Some staff spoke positively about these changes, whilst others were apprehensive about cross site working. Not all staff knew who the Matron was for their department. Most staff felt able to raise concerns or personal issues with managers and reported feeling supported during incidents. However, some staff said leaders were less approachable. Senior leaders were aware of this and had an action plan to support with development in this area.

Leaders understood where workload was not distributed evenly due to demand and acuity and were addressing this to provide safe care. Teams were undergoing consultations around rotational working, caseloads and equity of work. Preceptorship programmes were supporting this transition to boost competency and confidence.

There was a focus on developing Band 7 roles and responsibilities to ensure they fully understood operational oversight and compliance including audit.

The service stated full compliance with the maternity incentive scheme (MIS) had been achieved. MIS is an initiative designed to improve safety by incentivising compliance with 10 core safety actions, including staffing, training, learning, care, governance, service user voice and board oversight.

A safety champions board had been created and work was ongoing around the subgroup structure. There were plans to launch a patient safety and learning forum and develop a safety and quality team. There were local safety champions from all staff levels and regular bi-monthly walkabouts where all safety champions were invited to attend, including non-executive directors, freedom to speak up guardians and the ICB. A poster was created with the findings from the session and this was shared with staff. The safety champions board met quarterly and reported to quality joint action committee (QJAC). This was an improvement.

We scored the service as 2. The evidence showed some shortfalls. People did not always feel they could speak up and that their voice would be heard.

The service had been through intense scrutiny and unexpected challenges which created increased demand and workloads for all staff. As a result, some leaders had not been able to respond to staff and complete actions in a timely way. This had an impact on staff morale and wellbeing. Some historic issues had not been resolved. This resulted in long term concerns reaching crisis point. We were told leadership roles were being supported to improve responses.

Staff had access to Freedom to Speak Up Guardians and reported finding them supportive. There had been an increase in the number of concerns raised in maternity services during the previous quarter. There had been 16 concerns raised but 1 concern in particular had been raised by 7 different staff, therefore there were 10 different concerns.

Themes from concerns included communication, leadership, wellbeing and behaviours.

However, leaders tried hard to listen to staff. We were given an example of a member of staff who wished to remain anonymous and senior leaders had met with them in a way which protected their identity so they could hear their concerns. Themes were shared with the service leadership team and trust board. We heard how valued these conversations were. In most cases leaders were aware of the intelligence Freedom to Speak Up Guardians shared with them.

We scored the service as 2. The evidence showed some shortfalls. Training targets had not been met. Actions identified to improve equality, diversity and inclusion were not yet embedded.

Staff were trained in equality, but we did not see evidence of this including diversity and inclusion, 68% staff were in date for the training which was below the target.

The trust initiated a deep dive in July 2025 to review equity and included the findings into the equality, diversity & inclusion (EDI) improvement plan. Some of the actions for workforce EDI included embedding EDI objectives in governance and training, targeted recruitment, leadership development and reflective practice. The target for completion dates varied between May 2026 and May 2027 and as such there was further work to do to improve diversity and inclusion in the service.

Staff were able to apply to work flexibly, for example, flexible working agreements to account for personal circumstances such as caring responsibilities and health issues.

Managers put reasonable adjustments for staff members to help them carry out their role.

We scored the service as 2. The evidence showed some shortfalls. The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

There was an improvement in the availability of up to date and reviewed policies in the service, but work was ongoing. At the time of this inspection 74% of policies were in date which had increased from 59% in March 2025. The clinical lead for the service was an obstetrician, and they had been working in the role full time since May 2025. New policies had been introduced, and some were in the process of being ratified.

Staff undertook or participated in local clinical audits. The audits were mostly sufficient to provide assurance and staff acted on the results when needed but this was not always in a timely way. There was a gap of 17 months between the data collection period and report publication with action plan for the management of sepsis. The data was collected between April and June 2024, the action plan was dated August 2025 with the report and action plan agreed in November 2025. A reaudit was scheduled for 2026. The last completed audit for time from decision to delivery of caesarean sections was November 2024. The most recent data collection and analysis had been completed but the draft report was with the lead clinician for the audit for presentation at the cross-county meeting, where proposed actions would be discussed and agreed.

The national perinatal mortality review (PMRT) standardised process was followed in the event of baby deaths. The trust criteria had recently changed to ensure the most serious patient safety incident investigations (PSII) were escalated to senior trust level for further scrutiny. It was unclear how the review of less serious concerns could be overseen at senior level.

The service had an action plan to meet the requirements of the Ockenden reports. However, we reviewed the action plan and this was not up to date.

Data collected in relation to the World Health Organisation (WHO) surgical safety checklist (a tool which aims to decrease errors and adverse events in theatres and improve communication and teamwork) had improved. The WHO safety checklist was audited quarterly with agreed actions and target completion dates. However, between October and December 2025 compliance was 82%. This was below the target of 100%. We were told the service was reviewing a potential system related issue. The trust had agreed a single system was required to improve consistency and support clearer monitoring of compliance. We reviewed the WHO checklist audit summary report and an agreed action for improvement was to share the report at labour ward forum. We reviewed the minutes of the labour ward forums for August 2025, November 2025 and January 2026. Whilst risks in theatre and quality and safety updates were discussed; there was no documented discussion around the WHO safety checklist audit results or potential system related issues.

Since our previous inspection, governance processes had been refreshed. There was a perinatal governance lead, meeting structures had changed and there was cross site representation. There were quarterly perinatal meetings and a quality governance assurance group. There was a reporting structure up to executive level. Learning responses, experience and engagement, mortality reviews, labour ward forums, guidelines and audit, safety champions, maternity incentive scheme (MIS) and the maternity and neonatal improvement programme all fed into the perinatal governance group. The maternity and neonatal improvement programme comprised of 8 programmes with an assigned executive senior responsible officer. The programmes included safety and learning, workforce, culture and leadership, clinical pathways, governance, collaboration, estates and equality, diversity and inclusion. The maternity and neonatal improvement programme had its own dedicated program board and provided assurance quarterly. It was chaired by the non-executive director safety champion and was attended by the senior responsible officer. However, the interim perinatal governance lead was due to retire, creating a potential risk of loss of extensive governance experience. A succession plan was in progress, with a new lead appointed.

The trust participated in the maternity incentive scheme (MIS) year 7. They had declared themselves complaint against the safety actions. The MIS is an NHS resolution program rewarding UK hospital trusts for implementing safety actions to improve maternity and neonatal care.

There was a structured framework for ward and team safety meetings. This meant essential information, including learning from incidents and complaints, was consistently shared and discussed.

Risks for the maternity service were recorded on the divisional risk register. Each item had a score to determine the level of risk and discussed at the appropriate governance meeting where actions for risk controls were documented. We saw the top risks for the maternity service matched those articulated by the maternity leadership. Maternity and neonatal service pressures formed part of the corporate risk register.

Data and notifications were submitted to external organisations. The service submitted all qualifying maternity safety incidents to the Maternity and Newborn Safety Investigations (MNSI) programme, as required for NHS trusts. These incidents were investigated, safety recommendations made and action plans were developed.

The service held monthly perinatal governance group meetings chaired by the perinatal governance lead. The minutes showed areas discussed included service updates, guidelines and audits and exception reporting from forums (labour ward, patient safety and triage working group). At our previous inspection we found there was a lack of clear action and accountability from these meetings to drive improvement. At this inspection we found this had improved as these minutes included an action log and table.

Maternity safety champions held regular quarterly meetings with a set agenda. We were sent minutes from the meeting held in October 2025. PMRT reports, issues in triage, debriefing tools, maternity survey and the quarter 2 quality and safety report were discussed with actions documented. We saw safety champions posters for October, November and December 2025. Feedback from the walk arounds was shared during Maternity Safety Champion meetings.

The maternity triumvirate leadership team met weekly and the Quinumvirate (this included the triumvirate leadership team alongside the children’s services and neonatal leads) also met weekly. There was a quinumvirate action log which had 2 open actions and 6 in progress.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Leaders engaged with external stakeholders such as commissioners.

The trust was working with maternity and neonatal voices partnership (MNVP). The role of the maternity and neonatal voices partnership is to provide a service user voice in the development and delivery of maternity services. The chair of the maternity and neonatal voices partnership was a quorate member of meetings, therefore feedback was shared and the voice of women was heard at meetings. The MNVP had built a genuinely meaningful relationship with the maternity service and were passionate about their role. They had regular contact with leaders to make a difference to services provided to women.

Service leaders attended meetings with the Local Maternity Network System (LMNS) to review governance and incidents. The LMNS is a collaborative partnership for all maternity and neonatal care across Somerset, aiming to improve services, and maternity services are a key component of this local system, working within the wider Southwest Neonatal Network for complex cases.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Leaders we spoke with had a clear focus on the challenges and improvements were being made across the service. The service participated in 3 quality improvement programmes, these projects included reviewing the care bundle at instrumental delivery, the triage process and an escalation charter. These projects were identified through audit results and maternity and neonatal voices partnership were involved to include women’s voices into the data. Working groups were reviewing stages of the pregnancy journey and implementing action plans, for example in induction of labour and the increase in maternal requests for elective caesarean sections.

The service participated in the Maternity Outcomes Signal System (MOSS). This tool enabled services to monitor and respond early to signals with prompt safety assessments and actions regarding perinatal deaths. The service told us they had introduced a quarterly safety intelligence meeting. This meeting provided a platform for the evaluating and utilising service user feedback and safety intelligence to inform improvements within maternity and neonatal services. We were told perinatal deaths and any feedback from families involved in the PMRT process was included as an agenda item at the meeting.

A member of the team had been voted as ‘trainer of the year’ in the RCOG National Trainer of the Year Awards 2026. This award recognised exceptional trainers who went above and beyond to support and educate obstetrics and gynaecology trainees.