Leeds General Infirmary

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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last inspection we rated this key question as good. At this inspection the rating went down and we rated well led as inadequate. This meant the service management and leadership was below acceptable standard and did not ensure staff and patients had access to a well led service. Leaders and the culture they created did not support the delivery of high-quality, person-centred care. We found breaches of the regulations in relation to Regulation 17.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff we spoke with told us that local teams could work effectively together to ensure women received the best outcomes. There was a senior leadership and governance structure, which supported the women's clinical service units (CSU) consisting of Leeds Maternity Care and Leeds Centre for Women's Health.

There was a Women's CSU strategy 2024-2029 which contained objectives relating to the workforce, quality and safety and technology.

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Most midwifery nursing staff we spoke with did not know the service strategy however, were able to articulate the vision and future plans for the service including the creation of the new hospital.

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Staff described feeling motivated about changes ahead including the new hospital build which made them feel more positive about the future of maternity services once it was built.

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The completion of the new hospital was however, a number of years in the future and therefore we were concerned that staff and the Trust leadership were focusing on this development to the detriment of current service challenges and developments.

We reviewed the service action plan in response to the Maternity Incentive Scheme and Saving babies Lives care bundle and saw the service exceeded the national trajectories set to demonstrate ongoing compliance and improvements with all six elements of the bundle.

Staff at all levels told us they did not feel that senior leadership understood the staffing needs of the maternity services. Some staff told us they felt there was a lack of acknowledgement of the differences between maternity and nursing staffing needs. We heard that there was oversight of the service but not always a detailed understanding from a midwifery viewpoint. Staff felt there was a lack of transparency and clarity regarding plans to increase establishment following the most recent staffing review using a nationally recognised tool.

Staff told us they were reluctant to raise concerns and incidents because they found the Trust had a blame culture rather than a learning culture. Not only did this mean there was a reluctance to report, it also meant CQC had a lack of confidence in the robustness of the investigation process. Some staff also told us they thought some things were `brushed under the carpet' rather than dealt with openly.

Staff were concerned about the repercussions of raising concerns and reporting that they had made an error because they felt that they would be blamed as an individual rather than the incident be reviewed holistically to identify root causes.

The senior leadership team was led by a triumvirate which consisted of a Clinical Director, a Head of Midwifery and Nursing and a General Manager. Two sub triumvirate teams further supported the structure. These split into an obstetrics team and a gynaecology team. There was no Director of Midwifery at the time of inspection, although the service planned to recruit into this role in 2025. Although geographically separate the maternity services at LGI and St James hospital are managed as a single maternity service. We also saw there was no Non-Executive Director specific to the maternity service.

Staff told us that they felt supported by their immediate clinical leads and felt able to speak to the shift managers about concerns or personal issues. Several staff however described frustrations due to the ongoing operational staffing challenges and the lack of feedback from senior leaders in response to this. Staff reported feelings of hostility from board level and a reluctance to speak out freely because of this.

Staff told us they had reported incidents regarding medical staff behaviour which had impacted their own mental health. We interviewed senior leaders to seek assurance as to what actions they had taken in regard to this but we were not provided with assurance that action had been taken to support staff affected by this. We interviewed the triumvirate team who felt these were isolated incidents.

The Trust had also identified concerns about the behaviours of staff across different disciplines and had initiated work across both sites to promote civility between staff. Some managers told us about the impact the lack of civility had had on the dynamics of teams such as increasing the risk to patient safety.

We were not provided with the necessary assurance that leaders had taken these incidents seriously and had investigated them as fully as would have been appropriate. Therefore, we were not assured that the culture within the service was a priority as concerns were ongoing and had been an issue for several months prior to our inspection.

During the inspection, staff continued to tell us that they were concerned about the behaviours of some senior staff. They told us that this led to them being reluctant to request support or help from their seniors such as overnight on call for fear of an adverse reaction. The result of this was an increased risk to the safety of patients due to the poor culture created by some people.

Staff were encouraged speak up within the maternity service as part of an open and supportive learning culture however, not all staff felt safe to do so.

The Trust had an established Freedom to Speak up process where staff could raise concerns if not addressed through the line management route. Staff were aware of this service. There were three freedom to speak up champions within the service, although staff had not raised any recent concerns with the freedom to speak up guardians.

Some staff we spoke with told us they felt confident to actively speak up and raise concerns without fear of detriment or reprimand. However, this was not the case for all staff, some of whom had concerns about upsetting senior leaders by doing so.

As part of this inspection, we encouraged staff to share their experiences anonymously online with us. We received a number of contacts from staff raising concerns. We used these to direct parts of our inspection, and they were escalated to the Trust for immediate awareness. They provided assurances that individual concerns had been investigated and actions were being taken.

The Trust supported work-based learner programmes and international midwife and medical staff recruitment to support diversity within the workforce. There was an equality, diversity and inclusion policy in place.

We looked at the National NHS Staff Benchmark survey 2023 and saw that although the percentage of staff experiencing bullying, harassment or abuse from other members of staff had fallen from 29% in 2019 to 24% in 2023 for all ethnic groups other than white, non-white staff still experienced higher levels than white staff (23.62% compared to 18.89%). This showed that although the figures were improving, there was still some disparity based on race or ethnicity and further work to do.

The same survey also showed that in relation to equal opportunities for career progression, 65% of white staff believed this was the case compared to 54% of all other ethnic group staff. Ethnic minority staff did not believe that they had the same opportunities for career progression as white staff.

We further looked at the Workforce Disability and Equality Standards results for the Trust. These showed the following, staff with a long term condition or illness were more likely to experience harassment, bullying or abuse from a manager than staff without a long term condition or illness (11.74% compared to 6.45%), they were also more likely to experience bullying, harassment or abuse from other colleagues (23.59% compared to 14.58%) and less thought there were equal opportunities progression or promotion, 57.65% compared to 62.94%). More staff with a long term condition also felt pressure from their manager to come to work despite not feeling well enough to perform their duties (27.58% compared to 18.07%).

Staff completed equality, diversity and human rights training and we saw the completion rate was 88% which was above the Trust target of 80%, at the time of inspection.

Leaders told us there was a process in place to take action to prevent bullying and harassment at all levels. We spoke with staff throughout the inspection about bullying and harassment. None of the staff we spoke with, raised concerns to us regarding these issues.

The Trust had processes in place to make reasonable adjustments to support staff in order for them to carry out their roles. The service was actively recruiting staff which included newly qualified staff and international midwives. There were maternity and neonatal safety champions which had a broad spectrum of representation including gender, ethnicity and disability.

The service had a governance framework and process to support the delivery of care.

The Trust used an electronic storage system for all Clinical Guidelines and pathways called Leeds Health Pathways. This system was used for primary and secondary care throughout Leeds and allowed all staff to search for guidelines and view them electronically using PCs or mobile devices. Staff were encouraged to view these documents electronically to ensure that the latest version was being accessed.

We reviewed the latest triumvirate meeting minutes which were held weekly and saw there was a standard agenda which included but was not limited to recruitment, risk review, escalation of concerns and workforce operational planning.

However,although ward managers told us that risk registers were in place, they did not always get the opportunity to attend meetings where updates and feedback would be received as they were often not supernumerary to ward staff numbers. We looked at the overarching risk register for obstetrics and gynaecology dated December 2024. We found that some risks, such as unreliable theatre lights, staff Entonox exposure, potential buzzer failure and insufficient numbers of resuscitaires. However, senior leaders were sighted on the plans and continued to address known risks. Risks were tracked and monitored through the Women’s Quality Assurance Group and the Trust Risk Management Committee.

Maternity services had a collective audit programme which was overseen by the Clinical Effectiveness Midwife and Consultant Clinical Audit Lead for Obstetrics and reviewed through the governance pathways of Community and Outpatients Department Quality Forum and Women's Assurance Group. We reviewed the latest Maternity Services Tracker produced from this audit and saw mandatory trust annual audit programme compliance rates were in line with trust targets.

The service used the perfect ward to establish a measurement tool in which to bench mark its performance. We reviewed the minutes of the most recent perfect ward meeting minutes dated November 2024 and saw that L44 staffing did not meet the needs of the acuity of the patients 67% of the time. Leaders within the service told us scores were being checked to ensure accuracy; however, we did not see evidence to improve staffing levels on this ward.

Incidents were reviewed against Patient Safety Incident Reporting Framework (PSIRF) national guidance and the Trust Patient Safety Incident Response Plan (PSIRP) to determine the method of investigation and appropriate review tool. We saw guidance for staff to ensure this was followed correctly. The service reviewed all fetal and neonatal deaths using the national Perinatal Mortality Review Tool (PMRT).

The service submitted six referrals to The Maternity and Newborn Safety Investigations (MNSI). When a Maternity incident was investigated by MNSI, the service was not required to carry out its own local investigation. However, trusts are required to satisfy themselves of any immediate learning. We reviewed incident listing reports and noted in many cases, there were no actions recorded, despite also being shown to have been reviewed and approved. Lessons learned were not dated for action or follow up.

The Trust’s performance in the 2024 Maternity Survey showed a statistically significant decrease in scores for 21 questions compared to the 2023 survey results, meaning that scores were considerably worse than the year before.

The questions that scored significantly worse in the 2024 survey highlighted some potential issues around interactions between staff and patients throughout the maternity pathway, with people not always feeling that they were being listened to or involved in decisions around their care or that they were treated with kindness, respect and dignity. People did not always feel that they were able to get help when they needed it during labour and birth and postnatally. Services users also felt they weren’t given enough support or information regarding their mental health during their pregnancy or after birth.

We saw a reduction in scores across key fundamental areas, for example pain management, respect and dignity, kindness and compassion, confidence and trust in staff providing care and treatment. Whilst leaders of the service acknowledged these results, we did not see an action plan to specifically address these concerns.

The Trust had mechanisms in place to carry out Patient Safety Learning Reviews (PSLR) and Patient Safety Incident Investigations (PSII). We reviewed these as part of our assessment and saw that these were completed appropriately.

In 2023, Leeds Teaching Hospitals NHS Trust had the highest rate in England with a rate of 8.42 per 1,000 births, compared to an average of 6.01 per 1,000 births for comparable trusts.

For births excluding congenital anomalies, the rate has been more than 5% higher than the average for comparable trusts since 2021 and was the highest in England (for births in 2023).

The Trust provided us with several policies, including the Trust’s Safe Staffing Escalation policy which directed staff to submit a red ward report when staffing fell short of patient acuity and could not be mitigated. Staff were encouraged to log all incidents including staffing concerns; however, many staff told us they simply did not have time to do so. Further, staff told us they did not have confidence that submitting red report made any difference.

We spoke with staff who had concerns about the ability to deliver good care to women and babies to due to staffing levels. Senior leaders acknowledged the increased demand in acuity and complexity of women, and birthing people attending the service and that this had increased regionally and nationally. They were unable to provide assurance that staffing levels met the birth rate plus staffing requirements of the women they cared for and we issued a warning notice in relation to this.

Staff told us about partnership working with other agencies across the community to support families in their ongoing journeys.

There were recognised partnership working arrangements in place with other regional services and tertiary referral centres. The team were active participants in the regional networks for sharing of best practice and learning from other maternity services within the region. Safety huddles were completed everyday Monday to Friday with all regional units. Further, the service actively engaged with the Yorkshire and Humber Clinical Maternity Network meetings including Maternity Dashboard Focus Group, Maternity Safety Learning Network and Yorkshire Humber MatNeo Patient Safety Network.

Leaders were actively involved with the Maternity Voices Partnership (MVP). This is a group of parents, volunteers and professionals who work together to help shape and develop maternity services in Leeds and surrounding communities. The maternity service in collaboration with the (MNVP) had hosted an educational event for multidisciplinary staff and midwifery students from a local university. This was an opportunity to share learning and shape practice through listening to the patient voice within the areas of maternity where inequalities exist.

The Trust also worked with local universities, offering placements to students with a view to encouraging them to join the Trust after graduation. Additionally, the Trust had undertaken a piece of work with a local university, examining the local culture and to improve civility within and between teams.

The organisation worked with Maternity and Newborn Safety Investigations (MNSI) following patient safety incidents such as maternal and some baby deaths responding to investigation action plan requirements.

However, although the Trust stated that it worked with families when things went wrong, this was not always the case and we saw that families were not always invited to give feedback and when they did, this was not always valued by the clinicians involved. This diminished the value of patient experience and its’ importance when delivering person centred care.

We found significant shortfalls around the processes of learning from incidents, and actions were not taken in a timely way.

The Trust was an early adopter of the Patient Safety Incident Response Framework, (PSIRF), a nationally designated process for recording and responding to patient safety incidents. The framework was applicable to all services, not just maternity services. The service followed the Patient Safety Incident Response Plan, which sets out how the Trust will respond to patient safety events. However, it was not consistently applied.

Action logs were poorly completed, with no timescale for improvement recorded and no triangulation of learning from incidents. We observed basic information recorded against learning following incidents with generic statements used rather than detailed analysis and accountability. The information provided did not provide any detail of the incidents or actions to ensure further incidents were prevented.

However, when we spoke with staff, they were clear that innovation and involvement in new projects was a lower priority than ensuring there were adequate staff at the front line. Many of the project midwives told us their projects were on hold because of staffing pressures. Staff described the need to prioritise day to day clinical delivery over innovation, which acted as a barrier for proactive improvement work.

None of the staff we spoke with were able to describe learning following recent incidents. Staff told us learning following incidents could be shared at staff meetings, but these were not consistent across the departments we visited. Staff also told us that when they reported incidents and requested feedback, this was rarely received leaving them unconfident that any action had been taken or lessons learned.

We did however, see multiple examples of how the service had made changes following feedback from women and families using the service and families were offered the opportunity to be involved when PMRTs took place.