St Mary'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

At our last assessment we rated this key question Good. At this assessment the rating is 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.

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 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of women and their communities.

Services at Portsmouth Maternity Centre were provided under the Women and Children’s Care Group within Portsmouth Hospitals University NHS Trust. Portsmouth Maternity Centre was managed by a lead midwife who was supported by the community matron for the trust. The community matron reported to the Director of Midwifery (DOM) and Head of Midwifery (HOM) for the trust. The maternity leadership structure was changed to provide a better oversight of maternity services across the organisation with the DOM overseeing all organisations within the trust, with a head of midwifery at each location alongside matrons and specialist midwives.

The service had a shared vision of maternity and neonatal services across organisations within the trust. The vision was to provide equitable maternity care, be an inclusive safe place to work, in an organisation who are committed to deliver the national ambitions. Staff could explain how they were working to deliver high-quality care.

The mission statement was to reflect and provide compassionate, high-quality maternity and neonatal care to families across the organisations through dedicated multidisciplinary teams. The goal was to ensure every pregnancy and birth was safe, supported and personalised. There were 6 core enablers to support the delivery of the maternity and neonatal vision which were, leadership, safety, quality and governance, culture, effectiveness, person centred and learning and improving.

An overarching safety improvement plan was in development to include safety, quality, workforce, culture and incorporating women and their families experience. Each area of the plan included actions, timelines, and supporting evidence which is then provided to the board.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Senior and local leaders had the skills, knowledge and experience to perform their roles. The lead midwife had extensive maternity experience and had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high-quality care. The community matron supported the lead midwife and worked across both birthing centres.

Staff told us local leaders were visible in the service and approachable for patients and staff. Staff spoke warmly of local leaders and told us they felt supported by them. However, staff told us the maternity and trust senior leadership team rarely visited community bases or midwifery led units.

The maternity service had a team of professional midwifery advocates (PMA), who provided pastoral support and restorative supervision to staff. PMAs had implemented initiatives, such as supporting maternity staff to congratulate each other and to recognise great work.

The maternity safety champions last visited the main maternity unit in February 2026 and planned to visit Blake Maternity Centre in 2026 to engage with staff and gain assurances regarding safety for maternity services. However, there were no planned visits to Portsmouth Maternity Centre.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where women felt they could speak up and their voice would be heard.

Leaders at all levels and staff demonstrated openness, honesty, and transparency, with many staff reporting their local leaders were approachable, listened attentively, and provided regular feedback. Staff said should they have concerns about disrespectful, discriminatory attitudes towards patients they could do so without fear of the consequences but had never had to do so.

There was trust freedom to speak up (FTSU) available for maternity staff and the service had 2 FTSU champions to support maternity teams who were based at the main hospital.

Staff spoke openly about their work and how they supported patients, due to the unit size they were a small close-knit team. We heard how some staff were reluctant to attend the main hospital site as they did not feel it had the same feeling.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Senior leaders worked closely with the local maternity and neonatal voice partnership (MNVP) to contribute to decisions about care in maternity services. Following on from feedback from the MNVP the service introduced more photos and images using women and families from a diverse background.

The trust supported a programme to support staff from global majority to develop their roles. The programme called ‘Beyond Boundaries’ helped staff develop skills, including coaching, understanding themselves and others through compassionate and inclusive leadership and positive influencing.

Alongside the local maternity and neonatal systems (LMNS) worked towards a 3-year equity and equality report. The trust had a maternity equality and diversity steering group who analysed data from saving babies lives, continuity of care and ethnicity data collection to identify and reduce inequalities.

We scored the service a 1. The evidence showed significant shortfalls. The service did not have clear systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes. We found safety concerns raised to leaders during our inspection that had not been identified by the service. The service was operating under pressure which meant women did not always receive the same quality of care.

Governance systems did not consistently provide senior leaders with meaningful, location-level information to effectively oversee performance, quality and risk at Portsmouth Maternity Centre. Performance information was maintained across multiple documents and spreadsheets, and senior leaders were unable to demonstrate that they had access to clear, consolidated data to support effective oversight of the service.

Following the assessment, we requested additional performance information; however, the data provided lacked sufficient detail to demonstrate what was being monitored, how performance was being measured, or how information was being used to drive improvement.

The maternity dashboard did not clearly present performance against key maternity indicators. As a result, the service could not demonstrate how senior leaders assured themselves that performance was being monitored against national standards or how areas requiring improvement were identified and addressed.

Whilst governance meetings identified concerns and agreed actions, the service was unable to provide action logs or other evidence demonstrating how actions were tracked to completion, monitored for effectiveness, or embedded into practice. This meant the service lacked assurance that governance actions were consistently implemented and resulted in sustained improvements.

Senior leaders were also unable to demonstrate effective local oversight of workforce performance and compliance at Portsmouth Maternity Centre. Staff survey results were only available at trust level and were not reported specifically for maternity services or Portsmouth Maternity Centre. Although senior leaders told us workforce wellbeing had improved, they were unable to provide supporting data to substantiate this or demonstrate how workforce experience was monitored at a local level.

Similarly, training compliance information was only available at trust level and did not provide assurance regarding compliance, training gaps or emerging risks specific to Portsmouth Maternity Centre. As a result, senior leaders could not demonstrate how they assured themselves that staff working at the location had completed required training or how local workforce risks were identified and addressed.

This meant the service's ability to assure itself that governance arrangements were effective was limited, that risks were being identified and managed appropriately, and that performance, workforce matters and quality were being effectively monitored.

Despite these concerns, the service had governance structures, defined lines of accountability and established committees for the oversight of quality, safety and performance. Senior leaders held regular meetings to review safety, quality, audit activity, workforce matters and improvement plans. Maternity governance meetings included multidisciplinary representation and considered incidents, risks, complaints, compliance with national guidance and local policies. The community team also held a monthly forum to share learning, review themes and promote consistency across community maternity services.

The service maintained a system for monitoring guidelines, policies, standard operating procedures and care pathways, with compliance reviewed through governance forums. Senior leaders also monitored compliance with the Maternity Incentive Scheme through committee structures and external review processes, including scrutiny from the Local Maternity and Neonatal System. However, weaknesses in performance reporting, action tracking and the availability of location-specific data limited the effectiveness of these governance arrangements in providing assurance at Portsmouth Maternity Centre.

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

Local independent midwives and doulas had been invited to the service to discuss patient care and pathways, this fostered open and honest communication.

The service worked closely and had positive relationships with the local Maternity and Neonatal Voices partnership (MNVP). The MNVP engaged regularly with senior leaders to ensure voices of women were heard and feedback was passed on. Senior leaders attended regular meetings with the Local Maternity and Neonatal System (LMNS) to review governance and incidents and worked with the MNVP to contribute to decisions about care in maternity services. Meeting minutes showed current work being undertaken between the local MNVP, maternity service and the LMNS. A Local Maternity and Neonatal System (LMNS) is an NHS partnership that plans, delivers, and improves maternity and neonatal care

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 women. They actively contribute to safe, effective practice and research.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for people and actively contributed to safe, effective practice and research.

The maternity booking appointments had been extended to make sure a perinatal mental health assessment had been undertaken and reviewed. The change was implemented as part of a quality improvement action from the perinatal mental health working group to demonstrate responsive governance and safeguarding psychological wellbeing in pregnancy. The aim of the extended booking session was to complete a detailed history, identify any potential risk, have a trauma informed discussion and to put a plan in place to support their care.

Staff we met were committed to learning and improving services. They had a good understanding of quality improvement tools and had the skills to use them. Senior leaders encouraged innovation and research.

Community teams also held a monthly forum to share learning, review themes and promote consistency across community maternity services. This supported the sharing of best practice, learning from experience and identification of opportunities for service improvement.

Trauma-informed care was included as part of the mandatory annual trust update for all staff. This meant staff across maternity were trained to recognise trauma, respond sensitively, and adapt care to reduce the risk of re-traumatisation. This training was in line with national practice in perinatal mental health care. However, we were not supplied with evidence to determine how many staff had completed the training.