John Radcliffe 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

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 assessment, we rated this key question good . At this assessment, the rating remains the same.

Good: This means the service management and leadership had made improvements. Leaders created a culture to support the delivery of good quality, person centred care. However, we found issues with maternity governance which were fedback to leaders.

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 had a shared vision, strategy, and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Oxford University Hospitals NHS Foundation Trust had developed a trust-wide strategy and vision in 2023 with a 5-year plan. Women’s health, maternity, and neonatal fed into the strategy and offered a complete package of services which was linked to commissioning of services within Oxford. The strategy focused on 4 core aims and set out to close the inequality gap and make sure women felt listened to, supported and experienced high quality compassionate care informed by research and innovation. However, the strategy was not fully embedded and there was still a lot of work to do.

Leaders were driving improvements in safety in maternity and neonatal services. Maternity services had implemented the ‘Perinatal Improvement Programme’ which was phase 2 of the ‘Maternity Services Improvement Programme’ focusing on critical safety elements such as maternity triage, reducing delays in the induction of labour and improving service user experience and staff wellbeing. However, evidence confirmed the service still struggled with delays in the induction of labour pathway.

Leaders had woven third party community services into the strategy including perinatal mental health provision, wider safeguarding, and community services for vulnerable women for example, those who had experienced domestic violence.

Staff understood the vision which was to work with partners to deliver the right care in the right place and increasing capacity in the community setting to reduce the number of women admitted to the hospital.

Staff working in the community at the midwifery led units provided care that linked into the strategy and enabled women to access local antenatal and postnatal services and support. Staff working in those areas felt enabled to provide more personalised care.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing.

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. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had the skills, knowledge and experience to lead maternity services effectively. There was a clear leadership structure, with accountability to the trust board through a quadrumvirate comprising the director of midwifery, clinical director, neonatal clinical lead and directorate service manager, supported by board-level maternity and neonatal safety champions.

Leaders demonstrated a strong understanding of services and the challenges faced by teams, including increasing maternal complexity and a diverse population. They were building foundations for improvement through workforce restructuring, boosting staff morale and strengthening systems and partnerships. Leaders responded to public scrutiny with meaningful engagement and maintained transparency.

Leadership roles and responsibilities were clear, and leaders could articulate how care was delivered and the steps to improve quality and safety. Independent oversight strengthened governance and accountability.

A non-executive director (NED) provided challenge and scrutiny to ensure statutory obligations were met, acting as a guardian of governance with a clear focus on maternity quality and safety. They spoke openly and realistically about the significant challenges facing maternity services and demonstrated an understanding of the needs of the local community. They understood the complexity of caring for a high volume of high-risk pregnancies, as the unit was a tertiary centre with the highest level of care (Level 3) neonatal intensive care unit serving Oxford and surrounding areas.

The NED engaged with staff, attended bi-monthly meetings with safety champions, completed walkarounds, and reviewed risks. They presented data at board meetings and understood key areas of concern, such as delays in induction, and high rates of postpartum haemorrhage. The NED recognised and valued the healthy reporting culture, which supported learning and identification of themes.

A national maternity improvement advisor supported Oxford University Hospital NHS Foundation Trust as part of the Maternity Safety Support Programme made up of midwives and obstetricians. The trust had entered the programme because of the CQC’s last inspection. Maternity leaders had fully engaged with the programme which identified and supported the development of an increased leadership team.

Staff told us that the head of midwifery was visible and approachable and had an open-door policy so that staff felt enabled to raise concerns and challenges.

Leaders fostered a culture of transparency and learning from incidents. Actions from incidents were disseminated to staff via newsletters, safety huddles and team meetings.

Identified barriers to improvement included the commissioning of maternity services which did not work to the services and women’s advantage. This was attributed to the integrated care board’s predictions of activity which did not match the acuity and capacity to meet patient demand.

The service fostered a positive culture where people felt they could speak up, and their voice would be heard.

The service had made improvements to the freedom to speak up policy and process. There was a designated freedom to speak up guardian (FTSUG) who worked part time across the hospital. They received training from the National Guardians Office. Their role was to promote a culture where people felt confident to raise concerns about patient safety, their working environment, staffing and inclusivity.

The FTSUG worked with leaders and the human resources department to identify concerns and raise awareness on how to report concerns. They had helped develop an anonymised feedback process via the trusts internal intranet so that staff were enabled to speak up.

Staff were offered freedom to speak up training and the service worked to identify freedom to speak up champions within maternity so that staff had alternative ways to raise concerns.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

At our last inspection, we told leaders they must improve the culture and ensure active encouragement of staff to raise concerns and clinicians to collaborate in improving the quality of care. During this assessment, we found this had improved. For example, leaders introduced a clinical psychologist who focused on staffs’ emotional wellbeing and was available for staff working in maternity 2 days a week. The psychologist had seen over 80 staff members since the service was introduced. The psychologist evaluated outcomes which fed into outcomes of the staff survey.

Current leaders were proactive in making improvements to culture and staff wellbeing across maternity. They recognised that evidence showed that a poor culture led to poor outcomes. The service was awarded in house recognition with the ‘Improving Safety on the Frontline by Investing in the Workforce Award’ for supporting their colleagues. Service leaders had implemented initiatives including increasing the number of professional midwifery advocate roles and the recruitment of internationally educated midwives.

The trust had an Equality, Diversity and Inclusion (EDI) strategy aligned with the Equality, Diversity, and Inclusion Objectives (2022 to 2026), focusing on tackling inequalities and improving recruitment processes. Anti-bias and anti-racism training was informed by feedback from diverse ethnic groups and international staff. Two EDI midwives provided targeted support, including outreach to night staff and international midwives who were less likely to speak up. They worked with staff networks such as networks for people from ethnic minority groups, disability and accessibility, and women’s groups to provide a safe and supportive environment to connect and share experiences.

Awareness initiatives led to an increase in staff raising concerns, mainly about workload, organisational change, behaviours and perceived harassment. Some staff from diverse backgrounds reported feeling valued but noted they were moved between areas more frequently than others.

Leaders offered staff psychological support by employing a psychologist who was active in engaging with staff who had been involved in traumatic events. This was coupled with the implementation of the equality, diversity and inclusion policy.

Leaders monitored equality through staff engagement to ensure diversity in its make-up and representation of the patient group. This was reflected in the most recent international midwifery recruitment campaign.

Feedback from the 2024 staff survey showed 75% of participants were happy with the standards of care provided which was a slight improvement on the previous year. However, the survey data did not state the number of staff that completed feedback. The survey showed that there were 73 areas where staff scored the service lower than the previous year. With many staff feeling undervalued.

The governance processes were not always robust, plans for improvement were not supported by deployment of adequate staffing and we found gaps in some standard operating procedures and limited resources, lack of planned maintenance and adequate equipment. They did not always act on the best information about risk. However, they monitored performance, and outcomes and shared this securely with others when appropriate.

Governance structures were not always effective to identify all significant risks in the service Although there were extensive and well understood governance processes, these had not identified significant concerns we found during the assessment. There were aspects of care that were not always safe, like the configuration and staffing of the observation area, this meant there was an increased risk of harm to women. Changes to safe systems and pathways were not fully embedded.

We had significant concerns about several aspects of care and treatment. There was a lack of clarity about the purpose of the observation area and risks to the delivery of care had not been identified and there were gaps in patient facing medical reviews and CTG ‘fresh eyes’ on the delivery suite which did not align to national standards. Staffing was insufficient in areas of the hospital like management of induction of labour, maternity triage, and the community midwives ‘on call’ system was not supported by a robust community on call escalation operating procedure which meant community staff had increased workloads because they were called in to cover hospital shifts. We also found issues with equipment maintenance and the safe storage of medicines, and we were concerned about the lack of privacy and dignity for some women experiencing bereavement.

Staff did not always have access to the equipment and information technology needed to carry out their roles. Contributing factors included dual electronic patient record systems, issues with CTG Wi-Fi connectivity, and gaps in the planned preventative maintenance scheduled equipment checks. Data from the risk register showed funding was not consistently available to make required improvements to equipment and services. Lack of meaningful investment is known to negatively impact patient safety. Leaders recognised these challenges and sought alternative funding sources, including charitable funds.

Dual electronic patient record systems posed a risk because information was not readily available on both systems simultaneously. For example, diagnostic blood results and medication. Also, the divisional risk registers highlighted concerns about the storage of handwritten data, such as CTG printouts. Measures had been implemented to mitigate these risks, but monitoring was ongoing and there was no current evidence to confirm the effectiveness of improvements.

The governance team monitored the maternity and neonatal dashboards and used the data to create a monthly maternity quality report which included a thematic summary and shared with the trust board for full oversight. The dashboard was sufficient to provide assurance and evidence showed that leaders acted to improve services based on themes identified through audits. However, improvements were ongoing and not fully embedded into practice.

Leaders and managers maintained the maternity risk register at ward and directorate level. Staff at ward level could escalate concerns via the incident reporting system when required. Data showed there were currently 37 recorded risks, 5 scored over 14 which was high risk.

Records showed that maternity’s top 3 recorded risks were delayed induction of labour, inability to provide clinical oversight of ultrasound quality assurance and staffing of overspill for elective caesareans which led to less staffing of induction of labour.

There was a potential risk in delays in ultrasound scans due to staffing issues, which could compromise patient safety. This risk was ongoing at the time of writing and recruitment campaign was planned for December 2025 to address the situation. Although NHS England data showed compliance met key performance at 99.5%.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care. Information was in an accessible format, and was timely, accurate and identified areas for improvement.

Staff followed the ‘Incident Response Policy (2024)’ which detailed the emergency planning, resilience and response arrangements to provide suitable responses during significant critical or major incidents that affected business continuity.

Obstetric teams followed a recently implemented an obstetrics staffing escalation operating procedure and met monthly to review and escalate staffing concerns when required.

The governance team had a process for triaging incidents Monday to Friday and escalated moderate and above levels of harm via the patient safety meeting. Patient safety incidents were reviewed using the ‘Patient Safety Incident Response Framework (PSIRF)’ and a multidisciplinary approach to review these. Incidents were assigned to the relevant teams for investigation and response.

The Maternity Clinical Governance Committee completed monthly reports for the trust board. Records confirmed that leaders reviewed a three-year delivery plan for maternity and neonatal services.

Maternity reports to the board included progress of the perinatal improvement programme phase 2 which included a focus on service user experience, staff wellbeing, safety and continuous improvement.

The service reported progress on year 7 requirements of the Maternity (perinatal) Incentive Scheme (MIS) which showed potential areas of concern related to neonatal staffing.

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.

Maternity leaders maintained meaningful communication and engagement with external stakeholders, including commissioners and the maternity and neonatal voices partnership (MNVP). They were open and receptive to concerns about care, which led to scrutiny from government bodies, third-party organisations, and women’s action groups. This additional oversight created significant extra work for staff across maternity services; however, leaders remained committed to meeting their improvement targets.

The MNVP lead had built a strong relationship with maternity leaders. The maternity safety champion met monthly with the MNVP lead, who also had direct access to the director of midwifery. This meant that concerns raised by women via the MNVP were fed back to leaders to help improve patient care systems and pathways. An action to include a member of the Maternity and Neonatal Voices partner as part of the PMRT meeting showed a candidate had been appointed in June 2025.

The service acknowledged challenges arising from external campaign groups raising concerns about historic poor outcomes, which led to increased stakeholder reviews and scrutiny. Leaders maintained transparency and accountability throughout this process and recognised the impact on staff wellbeing. Staff told us they understood the concerns and were committed to making improvements despite the pressures of heightened oversight. Despite these challenges, staff reported meaningful improvements driven by leaders, including a stronger focus on staff support and service development, contributing to a more positive working environment.

A ‘Triangulation and Learning Committee’ was created to triangulate feedback data from multiple sources to develop and implement actions that addressed themes in a systematic and timely manner. The committee met monthly and comprised of leaders, specialist midwives and patient safety partners to review and act on service user feedback, review safety themes, legal claims, patient experience and operational representation.

Leaders had implemented a ‘Say on the Day’ feedback reporting system via a tablet in antenatal areas. Feedback data captured meaningful information including ethnicity which meant the service understood the vulnerabilities and known risks associated with ethnicity. The introduction of the ‘Say on the Day’ system had improved patient feedback and in July 2025, data showed that feedback represented 47% of deliveries for the month. Most feedback was positive. Areas for improvement included communication and wait times in antenatal clinics.

Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback. This was because the service offered debrief sessions for women and families who had birth trauma and poor care experiences.

Multiple stakeholders requested individual assurances from the trust, creating significant time pressures. In addition, staff working throughout maternity felt the pressure of the media attention and scrutiny. Leaders told us they wanted to prioritise engagement with families to learn and improve care; however, current levels of external scrutiny limited resources and the ability to distribute workload effectively.

Prior to the CQC inspection, maternity services had been closely monitored. The CQC had found that leaders were transparent and keen to work with action groups to make improvements, even though most of the cases were historic and occurred prior to the implementation of new leaders.

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 people. They actively contribute to safe, effective practice and research.

The service was on an improvement journey, and leaders were committed to strategies aimed at improving outcomes and experiences. Staff used quality improvement models to strengthen maternity pathways, although managers needed to make sure changes to practice were embedded and fully evaluated.

Innovations were evident. Leaders introduced weekend theatre lists to reduce elective caesarean delays and worked to improve induction of labour times to meet national targets. Monitoring was ongoing to ensure changes were embedded and safe. Staff had opportunities to participate in research and development improvement projects, leading to changes such as enhanced maternal and fetal medicine pathways. The trust led the way in fetal medicine and celebrated the first UK birth following a womb transplant.

The service addressed health inequalities by tailoring antenatal education for non-English speaking women through the ‘Flo’s ESO antenatal classes project’, which delivered meaningful sessions for people from diverse non-English speaking backgrounds and included access to interpreters. Maternal uptake for these specialist antenatal classes had increased since their implementation.

An ‘equality, diversity and inclusion’ midwifery-led inclusive initiatives, strengthened interpreting services, and supported projects tackling bias, screening equity and digital inclusion.

Wards participated in accreditation schemes and used learning from these to inform practice, like the UNICEF Baby Friendly infant feeding initiative.