Good Hope 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

At our last assessment published in June 2023, we rated this key question inadequate. At this assessment, the rating has improved to requires improvement. This meant the service management and leadership had improved but there was still work to be done to embed new processes, see sustained changes and ensure continued 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.

The trust had a strategy for 2024 to 2029 of `Building Healthier Lives' with 5 key priorities which aligned with the Local Maternity and Neonatal Services perinatal strategy. There was no individual strategy or vision for the department. The maternity service were adopting the LMNS strategy which it co-produced with the services users across the area. The maternity strategy had been finalised at the time of assessment and waiting hospital board approval.

Most staff felt respected, supported, and valued however some staff felt there were behaviours they considered uncivil. The service had launched civility and cultural training to improve culture and incivility. The trust had introduced a behavioural framework, and staff were receiving training around this guidance, produced in conjunction with staff and a major staff-led organisation within the trust (known as the Wise Council).

The service promoted equality and diversity in daily work and provided opportunities for career development. There were examples of staff who had been developed by the service including creating a new role and training an advanced care practitioner midwife.

Staff and leaders demonstrated a positive, listening culture that promoted trust and understanding between them and women using the service. However, there was little evidence of the cultural adjustments to improve outcomes in guidelines and practice.

The service was focused on learning and improvement. While the culture had improved since our previous assessment, there was still some work to be done. Maternity and Neonatal Voices Partnership told us there were still factions of staff in areas and at times, staff attitudes had a negative effect on the care women received. They felt the culture had improved from the leadership perspective, but it had not been fully embedded across the ward areas. A few staff felt underappreciated and not always supported by managers.

Equality and diversity were actively promoted, and the causes of any workforce inequality were mostly identified, and action was taken to address these. For example, student midwives had previously been to the university to raise concerns regarding incivility. The university had worked alongside the maternity department to improve this for the students who now felt it had significantly improved.

Not all staff felt there was equality. A few international doctors felt there was incivility and lack of equity, often they felt ignored and were overlooked for training opportunities. Other staff members told us the international doctors were valuable within their team and felt at times there had been a cultural shift due to differences in working but this had improved recently.

Service leaders reported they were working on a digital strategy which was 41% complete in February 2025.

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.

The leaders had the skills and abilities to run the service. The senior leadership team included the Chief Nurse, Director of Midwifery, Head of Midwifery, and a newly established Maternity Neonatal Improvement Programme team, alongside matrons, managers, and specialist midwives.

Leaders had the skills, knowledge, experience, and credibility, to lead effectively. They were described as acting with integrity, openness, and honesty. However, there had been leadership gaps in some areas, notably the delivery suite, which had been without a matron or manager for over 6 months. During this period, Band 7 staff stepped in to share responsibilities and to ensure the area ran effectively. Midwives praised the Band 7 team, particularly in the delivery suite, for their visibility and support despite high workloads. In contrast, some international doctors reported the support they received was inconsistent and feedback was not always constructive.

An interim matron managed the delivery suite during the leadership gap. This matron was visible, supportive, and knowledgeable, and credited with maintaining staff morale. At the time of the assessment, a new ward manager and matron had recently joined from another local trust within the Local Maternity and Neonatal Services.

Staff development was generally encouraged. Many midwives reported being supported to apply for senior roles and received guidance from practice development midwives. However, a few staff who had undertaken secondments and applied for senior positions were unsuccessful and felt unsupported afterward. This lack of follow-up support led a few to leave the trust due to limited development opportunities and lack of support.

The service promoted a positive and open culture where most individuals felt empowered to speak up and confident their voices would be heard. Staff and leadership demonstrated openness, honesty, and transparency, and staff were encouraged to raise concerns with their managers.

Most staff expressed positive views about the support and leadership within the service. They described an open environment where women, their families, and staff could raise concerns without fear of reprisal.

There was a Freedom to Speak Up Guardian and posters were displayed in maternity areas to raise awareness of this role. However, not all staff were aware of the Guardian or their responsibilities in supporting staff.

Despite these strengths, some staff reported ongoing issues with incivility and bullying, particularly affecting medical staff. Several staff shared feelings of isolation and noted frequent rota changes to cover shifts. Some also reported being discouraged from escalating concerns related to incivility and bullying.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff did not always act on the best information about risk, performance and outcomes. The service had clear responsibilities, roles, systems of accountability but these systems were not always used effectively.

Governance processes were somewhat effective in ensuring safety, addressing concerns, and delivering effective care but there was more work to be done. At the previous assessment, governance processes were not always effective. During this assessment, systems had been established to assess, monitor, and improve the quality of maternity care but they were in their infancy and still had some progress to ensure services improved.

Risks were not always highlighted which meant senior managers were not aware of patient’s outcomes and improvements needed. For example, postpartum haemorrhages were not recorded on the governance dashboard; this meant there was a lack of oversight and therefore action to reduce numbers of women who had a haemorrhage.

There were several issues with the documentation. These included errors, delays in ‘fresh eyes’ and missing documentation. None of these were highlighted by the governance team within their audits and there was no formal documentation audit. Managers were aware there were gaps in documentation, but there was no evidence of how improvement was being driven on the ward areas.

There were delays in triage, over scanning of patients, incorrect red-amber-green ratings and delays in medical reviews without resolution. These issues had not been highlighted on the risk register and we saw no plans for improvements to ensure women were seen in line with national guidance.

There was a dedicated maternity governance team, including a consultant obstetrician and anaesthetist. A detailed framework guided risk and governance management. Senior leads held regular meetings focused on safety, audit, quality, and governance. These meetings addressed key areas such as performance, risk, audit outcomes, culture, and workforce. Meeting minutes showed concerns were identified, and action plans developed, though not all actions were completed. While changes were ongoing, several improvement areas still required full integration into practice.

Local audits and reviews were completed, the sample sizes for fetal monitoring and contemporaneous record-keeping were not a representative sample size.

Audit results were shared with staff through email, daily huddles, and a private social media group.

Governance dashboards had recently been introduced, providing accurate and timely data. The governance team analysed this data to monitor performance and quality, recommending improvements as needed. Quality and safety were regularly discussed in governance meetings, and a monthly report was presented at the board level.

The service completed the ‘saving babies lives’ care bundle. We were told there were certain elements of it which the service was struggling to making improvements in. For example, Element 1: Reducing smoking in pregnancy was 60% at the time of the assessment. Managers communicated in forums, had been into antenatal clinic to reiterate the importance, and looked at individual level failing to try and address issues with non-compliance to the standard.

A governance newsletter kept staff informed, and a protected governance day was held quarterly, which staff found valuable and insightful. Additionally, a daily ‘real-time governance’ meeting, chaired by senior leadership, provided a platform for staff to raise and resolve concerns.

The service had multiple workstreams, including clinical governance. As of February 2025, 72% of the improvement actions in this workstream had been completed.

Band 5 midwives rotated into the governance and safeguarding teams for between 2 and 4 weeks; this was completed prior to becoming a Band 6. This was to ensure they understood the importance of documentation as poor documentation was their biggest issue.

There was a shared risk register for maternity services across 2 hospital sites. It was discussed at the obstetrics and gynaecology governance meetings. There were 7 high-risk items on the risk register which included:

• Risk to safe delivery of services due to insufficient maternity staffing.
• Insufficient capacity for induction of labour, leading to delays.
• Inadequate number of diabetic specialist midwives, impacting blood glucose monitoring.
• Risk of patient harm due to delays in inpatient admissions.

The service understood the duty to collaborate and work in partnership, but this did not always happen. Services did not always work seamlessly for people. Staff shared information and learning with partners and collaborated for improvement, but partners did not always feel actions were taken to make improvements.

The Maternity and Neonatal Voices Partnership team reported having positive relationships and engagement with the maternity service. However, they expressed concerns about not being informed or involved in the actions taken to drive improvements. This lack of communication made it challenging for them to provide meaningful feedback to service users.

However, a visit conducted by the Local Maternity and Neonatal Services in January 2025 highlighted significant progress since the launch of the Maternity and Neonatal Improvement Programme. Notable improvements were observed in staff morale and engagement, the condition of the estate, education and leadership, and workforce development. Feedback consistently emphasised the friendly, kind, and approachable nature of the staff. Despite these advancements, the local team noted further work was needed, particularly in sustaining cultural improvements and embedding the behavioural framework across the service.

Consultant midwives had actively engaged with charities and established a working group involving staff and the Maternity and Neonatal Voices Partnership to explore personalised care planning and evaluate hospital systems. Their aim was to use charities as a bridge to reach community health groups and to deliver joint teaching sessions for women. They also sought to understand the barriers women faced, gather their perspectives, and identify next steps for improvement.

Additionally, the midwifery-led unit had recently revised its philosophy and shared it with community groups to ensure it was culturally sensitive.

The service demonstrated a strong commitment to continuous learning and improvement, both within the organisation and across the wider local system.

However, information was sent mostly by email, which staff did not always have time to access. Consequently, there were gaps in awareness regarding ongoing developments and learning within maternity services.

Leadership maintained a clear focus on addressing challenges and driving improvements. This was supported by established maternity governance structures that reported to the board, alongside the use of data-driven maternity dashboards to monitor outcomes and inform learning.

Staff were actively encouraged and supported to dedicate time to improvement and innovation initiatives. Numerous working groups and projects were contributing to the enhancement of care quality for women.

In addition,the maternity and neonatal voices partnership was working with the consultant midwives to produce a pregnancy journey journal. This was a booklet that would be given to women in the community in different languages. The women could then document their language and specific needs for their care journey.