Queens 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 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 requires improvement. At this assessment the rating has stayed the same.

The service used governance process to improve patient safety. However, the service was in breach of Regulation 17 as the storage of placentae was not consistently overseen safely. 

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 shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. Service delivery did not consistently meet the needs of people and the wider community.

At our previous inspection, we found that the culture within the service did not consistently promote the trust's vision and values. At this inspection, we found insufficient improvement had been made and identified the same concerns about the culture of the service. 

We found leaders had developed a maternity transformation plan; however, this had not been effectively communicated to frontline staff, and there was limited evidence that staff felt engaged with or invested in the service's vision for improvement.

Some, but not all, staff described a culture where concerns relating to patient safety and staff wellbeing were not consistently acted upon. Although staff generally reported that their immediate managers listened to their concerns and were sympathetic to the challenges they faced, they felt these managers had limited ability to influence or resolve wider organisational issues.

Staff described a cultural divide between the labour ward and maternity ward. Maternity ward staff perceived that the labour ward received preferential support, particularly in relation to staffing and access to breaks. Staff told us they were frequently required to cover staffing shortfalls elsewhere within the unit, often resulting in reduced staffing levels on the maternity ward. They said this affected their ability to take breaks, complete patient records and access mandatory training. Staff also reported having insufficient protected time to review emails and important communications, including patient safety updates and changes to clinical guidance.

Staff working on the maternity ward described limited visibility of senior leaders, safeguarding teams and other key personnel based at the trust's other acute site. They felt this contributed to low morale and a sense of disconnection from decision-making within the wider service.

Although leaders had introduced a maternity transformation plan, staff below Band 7 had not been involved in its development. Leaders held monthly transformation meetings; however, many frontline staff told us they were unable to attend due to workload pressures or because the meetings took place on days they were not working. Staff were generally unable to describe the transformation programme. As a result, there was limited evidence that the organisation's vision, values and strategic objectives had been successfully embedded across the service.

We saw evidence the service had held an online session for staff to contribute to the perinatal strategy. However, data demonstrated that only 20 members of staff attended the session. 

Overall, staff experiences varied across the service; however, a significant number of staff reported low morale, limited engagement with senior leadership and insufficient involvement in service development and improvement initiatives. This reduced staff confidence that concerns would be addressed and limited shared ownership of the service's future direction.

Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

At our last inspection we found leaders did not create an environment in which staff felt empowered to raise concerns or challenge poor practice.  At this inspection, we found insufficient improvement had been made and identified the same concerns about the disconnect between leaders and staff.

Maternity services at University Hospitals of Derby and Burton NHS Foundation Trust were delivered across the Queen's Hospital Burton and Royal Derby Hospital sites and formed part of the Women's and Children's Division. The service operated under a defined cross-site leadership structure, including quadrumvirate service leads with responsibility for maternity services across both sites.

Staff consistently described their immediate leaders as visible, approachable and supportive. They told us local leaders were present within clinical areas, listened to concerns and promoted a culture where staff felt able to speak up. Staff felt their immediate leaders understood the challenges they faced and provided compassionate support when required.

However, some staff told us cross-site middle managers and senior leaders were not always visible at Queen's Hospital Burton because they were predominantly based at the trust's other site. Staff reported this reduced opportunities for engagement with some leaders and meant managerial support was not always readily available during periods of high clinical acuity. They told us this had a negative impact on morale and their perception of leadership visibility across the service.

Staff did not always feel they could speak up and that their voice would be heard.

At our last inspection we found staff did not consistently feel supported to speak up or raise issues. We found the same issue at this inspection. 

Not all staff felt confident that they could speak up and be assured that their concerns would be heard. Most staff spoken to were unaware of who the trust’s Freedom to Speak Up (FTSU) Guardian was and had a limited understanding of the role of the FTSU Guardian and their team. While one staff member reported seeing posters around the hospital promoting this information, awareness remained low overall.

Despite this, most staff said they felt comfortable raising concerns within their immediate teams and did not fear negative consequences when discussing issues with their line managers or colleagues.

Staff told us they no longer had access to a Professional Midwifery Advocate (PMA) for leadership, advocacy, restorative clinical supervision, wellbeing support. The absence of this support reduced opportunities for midwives to access independent professional advocacy and reflective supervision. Staff said this limited their confidence to speak up, share concerns and feel heard.

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.

Leaders promoted an inclusive culture and supported staff to work in ways that met their individual needs. Staff told us they were able to work flexibly to accommodate personal circumstances, including caring responsibilities. Managers considered requests for flexible working and implemented reasonable adjustments where appropriate. Staff had access to a range of working patterns, including 12-hour shifts, shorter shifts, day shifts, night shifts and the option to participate in on-call arrangements.

The trust demonstrated a commitment to equality, diversity and inclusion and had established several staff networks to support and engage its workforce. These included networks for Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, Intersex, and Asexual/Aromantic/Agender, and all other sexual orientations and gender identities (LGBTQI+) staff, disabled staff, black, Asian and minority ethnic staff, carers and members of the Armed Forces community. These networks were open to all staff and provided opportunities for support, engagement and raising awareness of equality issues.

The trust monitored workforce equality data and had systems in place to identify and respond to areas requiring improvement. The 2025 Workforce Race Equality Standard (WRES) report showed that 47.8% of the workforce identified as Black, Asian or from a minority ethnic background. However, representation of staff from minority ethnic backgrounds had reduced in some senior roles. For example, representation in Band 8d and above roles had decreased from 35% to 7.7%, and within the medical workforce had decreased from 55% to 32%. Trust data also showed the proportion of staff who identified as having a disability had increased to 6.8%. However, only around half of disabled staff reported there were equal opportunities for career progression, indicating further work was needed to improve the experience and development opportunities of disabled staff.

Trust leaders reviewed performance against the national WRES indicators. The trust reported improvements in three indicators, including reductions in the proportion of staff from an ethnic minority background reporting abuse, bullying or harassment from patients, relatives and colleagues. Two indicators remained unchanged and five had deteriorated. Leaders recognised these challenges and had developed an action plan to address areas of concern. Progress against the plan was monitored through the senior leadership team to support continuous improvement in equality, diversity and inclusion across the organisation.

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 with others when appropriate.

Systems and processes were not always effective in ensuring compliance with regulatory and safety requirements. During inspection, we found placentae were being stored in a sluice room that was accessible to patients and other unauthorised individuals. This did not provide assurance that human tissue was being stored in a secure, access-controlled environment in line with Human Tissue Authority requirements and the Human Tissue Act 2004. Furthermore, governance arrangements had not identified or mitigated the risks associated with the storage of human tissue and biological materials, including ensuring appropriate controls were in place to restrict unauthorised access in accordance with Control of Substances Hazardous to Health (COSHH) requirements.

Risk management processes were established and supported by regular multidisciplinary oversight. Monthly incident and risk meetings were attended by representatives from across the maternity service, including obstetricians, anaesthetists, midwives and risk management leads. The service maintained an up-to-date risk register with clearly described risks, assigned risk ratings, identified risk owners, review dates and mitigating actions. We saw evidence that risks were routinely reviewed through governance processes.

Risk management processes were not always effective in identifying, escalating and managing risks at site level. The trust's maternity risk register contained 33 risks, of which only four related to the Queen's Hospital Burton site. There were no recorded risks relating to staffing pressures or cultural concerns, despite these themes being consistently identified through staff feedback. This indicated a disconnect between the risks described by staff and those formally recognised through governance processes. Consequently, leaders could not be assured that all significant risks were being appropriately identified, escalated and managed, limiting their ability to take timely action to mitigate potential impacts on patient safety, service quality and staff experience

The service had a governance structure with clear lines of accountability and reporting. Staff generally understood their roles and responsibilities. However, staff feedback indicated that not all colleagues experienced a culture in which concerns could be consistently raised and escalated.

Leaders maintained oversight of quality, safety and performance through a comprehensive governance framework. This included a range of monthly cross-site and site-specific governance meetings that facilitated multidisciplinary review of service performance. We reviewed minutes from the Senior Governance Panel, Maternity Quality and Safety Assurance Group, Perinatal Mortality Review Tool (PMRT) meetings and the Maternity Virtual Incident Review Panel (VIRP). These demonstrated good multidisciplinary engagement and evidenced discussion of risks, incidents, quality indicators and service improvements. Action plans were clearly documented, assigned to responsible leads and routinely monitored to review progress and effectiveness.

The service used a maternity dashboard to monitor performance against key quality and safety indicators. Leaders regularly reviewed performance data to identify trends, monitor outcomes and inform improvement activity, supporting a proactive approach to quality assurance and service oversight.

However, there were not always effective arrangements for sharing information and learning across the service. Outcomes from governance meetings, safety reviews, and quality improvement activities were communicated to staff through newsletters, emails, and team meetings. Some staff told us they did not always have time to read emails, including those about patient safety although other staff told us they felt informed about patient safety improvements, service developments and opportunities for learning.

Incidents, complaints, and risks were reviewed in a structured manner, with action plans developed and monitored to reduce the likelihood of recurrence. Staff told us that families were involved in investigations where appropriate, ensuring their views and questions were considered throughout the process. However, the service did not consistently respond to complaints within the timescales it set for itself although there had been an increase from 25% in April 2026 to 50% in May. 

The service demonstrated a commitment to quality improvement and sustainability through support from the maternity and neonatal intensive support team (MatNeoIST). The service was actively engaged with the Maternity Incentive Scheme (MIS) and the Saving Babies’ Lives Care Bundle Version 3. Leaders used these programmes to drive improvements in safety, governance, and clinical outcomes. At the time of our inspection, the service was compliant with all 10 safety actions within the Maternity Incentive Scheme, providing assurance that nationally recognised standards for safe maternity and neonatal care were being met.

Patient records were maintained confidentially on secure electronic systems. During the inspection, we observed staff accessing care records appropriately and logging out of systems when record keeping activities had been completed. This helped to protect people's personal information and ensure confidentiality was maintained.

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 to improve service delivery.

Leaders demonstrated an understanding of the needs of the local population and the impact of health inequalities on outcomes for women, babies and families. They recognised the additional challenges experienced by ethnic minority groups and people from disadvantaged communities and sought to address these through engagement and service development. 

The service demonstrated a proactive approach to addressing inequalities in maternity outcomes. Working in partnership with the Maternity and Neonatal Voices Partnership (MNVP) they approached local community representatives to better understand and respond to the needs of women who experienced poorer outcomes, particularly those from diverse ethnic backgrounds. This had enabled them to engage with established community groups to identify areas for improvement and used this insight to inform service development and delivery. The service had also developed an information leaflet on uterine artery doppler examination which had been co-produced with MNVP.

This collaborative approach supported the service to take steps towards reducing health inequalities and improving outcomes. There were plans to further develop this work with other underrepresented groups who may experience worse outcomes, including women from traveller communities.

Through their work with MNVP it became apparent that there was sometimes a breakdown in communication between trust midwives and other people who women had chosen to be supported by, such as an independent midwife or doula. The breakdown in communication had led to some people feel their role in the pregnancy or birth was not respected. Trust midwives, doulas, and independent midwives had reported some strained working relationships through MNVP. To ensure all the people supporting women during pregnancy, labour, and postnatally worked together well the trust begun a project in May 2026 to look at how these relationships can be improved. 

The MNVP feeds comments from women and families into a database held by the trust in real time. This enables a swifter response. The trust also collated women’s feedback from social media platforms for review and response. 

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.

Leaders described a well-established improvement programme that operated across all trust sites and reported directly to the trust board. At the time of our inspection, there were 11 improvement workstreams in progress at various stages of implementation and evaluation. The programme provided a structured approach to identifying areas for improvement, monitoring progress and embedding sustainable change.

Several workstreams had demonstrated measurable improvements in clinical outcomes. For example, the fetal monitoring workstream was nearing completion as improvements had been successfully implemented and embedded into routine practice. A multidisciplinary group focused on reducing obstetric anal sphincter injuries (OASI) was reviewing a range of interventions aimed at reducing the incidence of severe perineal trauma. Outcomes from this work were being evaluated to inform future recommendations and clinical practice.

The service demonstrated a proactive approach to reducing rates of post-partum haemorrhage (PPH). A multidisciplinary PPH working group had introduced a structured documentation tool to record key clinical parameters, enabling detailed analysis of care and treatment outcomes. The tool had been reviewed and refined in response to learning. Data showed the rate of significant PPH had reduced from 52 per 1,000 births to 39 per 1,000 births. Although this remained above the national average of 31 per 1,000 births, leaders could demonstrate sustained improvement through a range of evidence-based interventions. These included the introduction of a clinical scoring system, changes to the management of the third stage of labour and the use of conical drapes to improve the accuracy of blood loss measurement.

Improvement work was supported by effective multidisciplinary collaboration. The PPH working group included professionals from all relevant specialties, including midwives, obstetricians, anaesthetists and laboratory staff. This enabled learning to be shared across disciplines and helped ensure improvements were informed by a range of clinical expertise.

The service routinely used data, research, incident learning and staff feedback to identify opportunities for improvement. Leaders monitored the impact of improvement initiatives and adapted programmes where necessary to achieve better outcomes for women and babies. This demonstrated a commitment to innovation, learning and quality improvement across the maternity service.

The service had a research cafe which reviewed articles of research in relevant publications. There was also a Research Strategic Development Group which was in the early stages of forming.

At the time of our inspection the service was participating in 7 studies, a further 3 studies had closed during 2026.