Gloucestershire Royal Hospital

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• 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.

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 service did not have a current strategy to provide a clear direction for future development and improvement. As a result, not all staff had a shared understanding of the service's priorities, creating a risk that improvements may not be fully coordinated or sustained over time. Staff feedback indicated mixed morale, with some staff lacking confidence they could speak up and have their concerns listened to, acted upon, and addressed effectively.

Most staff knew about the provider’s vision and values and how they were applied in the work of their team. We saw information regarding their compassionate culture which listed the behaviours and values desired of employees.

The service did not have a maternity specific strategy as the previous strategy concluded in 2024. The service was working on a new maternity strategy that aligned with the trust’s strategic plan. Senior leadership told us they had been concentrating on addressing the conditions on their registration and improving maternity care. Most staff felt the service they provided to women was improving with the additional external support provided and actions being taken. However, not all staff felt they could speak up about concerns and would be listened to.

Staff morale was divided. Some staff reported feeling anxious and uncertain about the service’s direction. Others welcomed the changes being implemented and viewed them as positive improvements. Overall, there were mixed perceptions of the culture, with concerns about changes and workload. This variation in morale and confidence had the potential to affect staff engagement and the consistency of care delivery.

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

Some staff reported senior leaders were not always visible or accessible and described a culture in which they did not feel confident raising concerns, with some perceiving a blame-focused approach. Although leaders demonstrated an understanding of the service and generally had the skills, knowledge and experience required to lead effectively, staff feedback about the culture was mixed. In contrast, local leaders were viewed more positively, with staff reporting they felt supported and able to raise concerns within their immediate teams.

There was a clear leadership structure for maternity services. The Director of Midwifery led the maternity unit which was part of the Women’s and Children’s services, and a Non-Executive Director held responsibility for maternity. Due to issues identified at the previous inspections and an inadequate rating, the Director of Nursing and other senior leaders were supporting the divisional leaders to drive improvements and maintain compliance with conditions on the provider’s registration.

Staff felt able to raise concerns or personal issues with ward managers and matrons and reported feeling supported during incidents. However, some staff said senior leaders were less approachable, and concerns were raised about a perceived blame culture rather than a focus on learning. Staff also reported some senior staff were not visible and they did not see them in the maternity department.

Local leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to improve the quality care.

Leaders had an understanding of the needs of the local population, including how health inequalities affected treatment and outcomes for women, babies and families from ethnic minorities and disadvantaged groups. They worked with various stakeholders such as the maternity and neonatal voices partnership (MNVP) and the local maternity and neonatal system (LMNS). They also attended various meetings and had a programme to improve the equity of experience and outcomes.

Senior leaders were not always consistently visible or accessible to women and staff. Matrons conducted Birth Experience Assessment Meetings (BEAM), engaging with women, families, and staff to gather feedback on care. Regular drop-in sessions were also held for staff, with dates clearly communicated. Safety champions completed visits and dates of these were announced.

Some staff lacked confidence in senior leaders' willingness to listen to and act on concerns, indicating issues in leadership visibility, responsiveness, and the promotion of an open culture.

Some staff reported feeling unheard or unfairly treated when raising concerns or whistleblowing. Investigations were often delayed, affecting staff wellbeing. Feedback highlighted issues with senior leadership, including limited visibility, a controlling approach, and a perceived blame culture around incident reporting.

Staff had access to a Freedom to Speak Up Guardian (FTSUG) and reported finding them helpful and supportive. The FTSUG was promoting a restorative culture focused on repairing harm and relationships rather than assigning blame. There was 20 Freedom to Speak Up Champions across the trust, independent of any specialty to maintain impartiality.

Managers and staff had access to the feedback from women and their family. Staff used the feedback to make improvements.

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.

Staff were supported in the workplace. 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.

Staff reported having opportunities to develop their skills and knowledge. The trust offered programmes to support unqualified staff who wished to train as midwives.

The provider undertook equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the patient group. We were provided with the Workforce Race Equality Standard (WRES) data for 2024-2025. Staff were asked a series of questions, and this was reviewed based on race. The data showed the number of staff from Ethnic Minority Backgrounds had increased across all bandings of staff in the Women’s and Children division. division.

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. Actions were not always implemented in a timely manner and compliance has taken considerable time.

The governance structure did not always support decision making processes. The trust had implemented a new governance structure in October 2024, and this included new forums which fed information into the pathway to the board. The governance team provided data to each forum and groups for example, incidents, and themes from learning. Feedback from other stakeholders was the trust was slow to implement improvements and sustain them despite having external support to address this.

The service reviewed stillbirths and neonatal deaths appropriately. Senior staff provided evidence the service used the Perinatal Mortality Review Tool (PMRT) to review stillbirths and neonatal deaths to identify causes, learn from them, and improve future care. Reports were completed by the PMRT group. All perinatal deaths received a multi-professional review before presentation at the Patient Safety Review Panel to ensure appropriate Patient Safety Incident Response Framework (PSIRF) learning.

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

In response to the national media programme broadcast on 29 January 2024, the Chief Executive Officer commissioned 2 independent external reviews: 1 examining neonatal mortality between 2020 and 2023, and a second reviewing maternal mortality and wider safety systems between 2018 and 2022. The learning and recommendations from these reviews were to be devised into an improvement plan. As the reports had only just been released at the time of our assessment and site visits, we were not able to review the actions in line with their action plan.

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 not always in a timely way.

The service had a risk register. Staff at ward level could escalate concerns when required. Each maternity area had a governance board for staff showing key information such as the top 3 risks, complaint numbers, and incident reports, including overdue cases. Boards were updated monthly. Risks for the whole of the maternity service were recorded on the divisional risk register. Each item had a score to determine their risk and were discussed at the appropriate governance meeting and actions for risk mitigation were documented. We also saw evidence these risks were discussed at board level. Examples of risks were lack of staffing and delay to women using triage for review, identification and treatment.

Senior staff networked with other maternity units within the southwest to learn from each other and share good practice.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients.

The service had an action plan to meet the requirements of the Ockenden report (2022) However, some of actions were still outstanding including workforce and sustainability.

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 and, where appropriate, safety recommendations were made. Action plans were developed to address the safety recommendations.

Following the assessment, trust leaders confirmed they had benchmarked the service against Royal College of Obstetricians and Gynaecologists guidance and identified areas of partial compliance. These risks were formally recognised, monitored through the trust’s governance arrangements, and maintained on the risk register. Oversight was provided through the monthly Perinatal Delivery Group, chaired by the Director of Nursing and supported by executive leadership, with a focus on key maternity safety and quality priorities, including Saving Babies’ Lives, perinatal quality and safety, and the NHS England Maternity Safety Support Programme (MSSP). MSSP is a national support programme provided by NHS England to maternity services where significant concerns have been identified regarding the safety and quality of services. The trust had also developed an improvement plan addressing staffing, estates, governance, data quality and patient communication.

The service collected and analysed reliable data. The trust submitted data to the maternity services data set (MSDS). The MSDS is a national dataset that captures patient-level information from the booking appointment until discharge we saw the service had passed all of the data quality tests.

Maternity safety champions held regular quarterly meetings with a set agenda. We were told actions from previous meetings were reviewed, as well as any quality improvement projects. We saw the Maternity Safety Champion, Director of Midwifery and Non-Executive Directors Walk Around schedule for 2025. Feedback from the walk arounds was shared during Maternity Safety Champion meetings.

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.

Directorate leaders engaged with external stakeholders such as commissioners.

The trust was working with the local Integrated Care Board (ICB) to undertake a maternity needs assessment. This involved gathering feedback from women and staff on their experiences and priorities for future service development. This insight was intended to identify gaps, inform targeted improvements, and ensure maternity services remained inclusive, responsive and equitable for families across Gloucestershire.

Service leaders attended regular 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 Gloucestershire, aiming to improve services, and Gloucester's maternity services are a key component of this local system, working within the wider Southwest Neonatal Network for complex cases.

At the time of the assessment the trust did not have a maternity and neonatal voices partnership chair. The role of the MNVP is to provide a service user voice in the development and delivery of maternity services This role was being overseen by the regional MMVP; however, funding had been agreed for a specific post to work with this trust.

The service did not always focus on continuous learning, innovation and improvement across the organisation. Staff did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. Staff did not always actively contribute to safe, effective practice and research. Improvements to the service took time to implement and imbed.

Staff and leaders were working to improve the service; however, progress had been slower than expected. The service had been rated inadequate since 2022, and conditions were imposed on its registration in 2024. Despite actions taken in response to identified concerns, leaders were unable to consistently demonstrate that improvements had been implemented at pace, embedded across the service, or resulted in sustained improvements in the quality and safety of care. The length of time since concerns were first identified limited assurance improvements were being delivered in a timely and effective manner.

Senior staff were implementing a version of the Maternity Disadvantage Assessment Tool (MATDAT). This tool was to identify complexity, risk, and need in early pregnancy. It could also be used to assess midwife-to-woman time requirements based on complexity, ensure fair and accurate caseload distribution based on women's needs, and support better outcomes and equity for women. Leaders had plans to expand its use, but this was in its infancy at the time of our assessment.

A new way of teaching and upgrading community staff skills and knowledge had been devised. This was called the ‘Skill Zone Safety Centre’ which was an immersive home setting, providing hands on insights into obstetric emergencies in the community setting. This started in June 2025 and staff in the community told us how beneficial they found this training as it was based in a home setting.

This trust was part of the Maternity and Neonatal Independent Senior Advocate (MNISA) pilot. This pilot is a trial program providing independent support to women, and families who've experienced serious harm, injury, or death during maternity and neonatal care in England, aiming to amplify their voices, help navigate complex systems, and drive learning for future improvements. These advocates ensure families feel heard, understand investigations, and find appropriate support, even if the issues extend beyond the initial providers, supporting system-wide change. This was due to close in early 2026 and senior staff from the trust will use the feedback to make changes to their service.