St James's University 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

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 an 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. The service was in breach of regulation 17 in relation to good governance at the service.

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.

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 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.

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 are 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.

Leeds Teaching Hospitals NHS 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. Staff also told us there was a feeling of hostility towards maternity services from Board level. Further, there was no maternity services representation by a non-executive director at Board level.

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.

We read the Trust’s Midwifery Workforce Planning 2024 document. The document identified that to date, labour ward coordinators did not have a recognised development pathway, as recommended by the Ockenden report’s immediate and essential actions. The Trust has started to work with the local midwifery network to review an existing national framework which can be modified and implemented. Staff can also shadow senior leaders, take lead on projects, and undertake education such as leadership diplomas. Additionally, the Trust supports the ‘aspiring heads and directors of midwifery’ programmes.

Staff were encouraged to 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 and some told us they had followed this route. There were 3 freedom to speak up champions within the service. 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 speaking up.

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. We escalated specific concerns with senior leaders at the time. 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. Staff completed equality, diversity and human rights training and we saw the completion rate was 88% which was better than the Trust target of 80%, at the time of inspection.

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 was needed.

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.

In relation to experiencing discrimination at work from a manager or team leader, the latest National NHS Staff Benchmark Survey showed that 5.72% of white staff experienced this compared to 14.93% of other ethnic groups.

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%).

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. The Trust had also held ‘Hear my voice’ events to encourage cohesion and understanding amongst staff.

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 senior leadership team was led by a triumvirate which consisted of a Clinical Director, 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 there was a cross-site head of midwifery.

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. We saw examples of an adequate governance structure, for sharing maternity safety intelligence.

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. Service 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 MBRRACE perinatal mortality data (based on births in 2022) showed that the stabilised and adjusted rates at the Trust, for neonatal mortality and extended perinatal mortality (stillbirths and neonatal deaths), were more than 5% higher than the average for comparable Trusts and the highest in England.

The latest MBRRACE perinatal mortality data (based on births in 2023) showed that the stabilised and adjusted extended perinatal mortality rates (stillbirths and neonatal deaths) at the Trust were more than 5% higher than the average for comparable Trusts from 2017 to 2023. There was also an increase in the rate from 6.68 per 1,000 births in 2020 to 8.42 in 2023.

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 had been more than 5% higher than the average for comparable Trusts since 2021 and was the highest in England (for births in 2023).

Ward managers told us that risk registers were in place, however, 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 had been on the risk register since 2019 with no reduction in their risk score. We also noted that the risk register did not record the risk of insufficient CTG machines. We were therefore not assured that all risks were recorded, reviewed at the appropriate level of seniority or up to date.

Maternity services had a collective audit programme which was overseen by the Clinical Effectiveness Midwife and Consultant Clinical Audit Lead for Obstetrics. This was 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 met in line with Trust targets.

The Trust had a Patient Safety Incident Response policy to support staff to report incidents, this aligned to NHS England guidance on recording patient safety events, and we saw guidance for staff to ensure this was followed correctly. This included which incidents required an investigation and those which did not.

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 itself of any immediate learning. We reviewed incident listing reports and saw in many cases action taken was recorded as nothing, despite also being shown to have been reviewed and approved. Lessons learnt were not dated for action or follow up.

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. We identified concerns with the robustness of these investigations.

The service also used Perinatal Mortality Review Tool (PMRT) reviews, when reviewing patient safety incidents and we saw these were completed where appropriate.

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 told to log all incidents including staffing concerns; however, many staff told us they simply did not have time to do so, and a small number told us they were discouraged from doing so. This was of concern to CQC because it meant that the Trust may not have had a true picture of incidences and brought into question why some staff were discouraging others to report staffing shortages. Further, staff told us they did not have confidence that submitting a red report made any difference.

Most of the staff we spoke with had staffing concerns affecting their ability to deliver fundamental standards of good care to women and babies to keep them safe. Some staff raised concerns to us about the accuracy of information reaching the board and one member of staff felt that figures were sometimes ‘fudged’ to show departments in a better state than they were actually in. They told us this was known to happen at matron level and above although we were unable to corroborate exactly how this was happening.

Senior leaders acknowledged the increased demand in acuity and complexity of women 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 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 and a further project exploring how resilient healthcare can be used to improve safety within maternity services.

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. We saw that this system had not been developed or enhanced in maternity services since introduction, to ensure incidents were consistently and robustly reviewed.

Action logs were poorly completed, with no timescale for improvement recorded and no triangulation of learning from incidents. We also saw only basic information recorded against learning following incidents with generic statements used rather than detailed information such as naming who was responsible for actions being completed. The information provided did not give any detail of the incidents or actions to ensure further incidents were prevented.

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 saw 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.

The Trust was keen to promote innovation and become involved in new initiatives. 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.

The Trust was currently running a project looking at the prevention of third- and fourth-degree tears and had also been chosen as a pilot site for the Avoiding Brain Injuries in Childbirth project sponsored by the Royal College of Gynaecologists (RCOG).