John Radcliffe 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 service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. This is the first inspection of the neonatal service. This key question has been rated good.

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.

We scored the service as 3. The evidence showed a good standard. 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.

Leaders had a shared vision, strategy and culture for the service, which was generally well understood by staff. The trust’s strategic priorities, including creating a positive working environment and embedding a culture of continuous improvement, were clearly communicated and displayed across the units. Staff across different professional groups were aware of the organisation’s direction and values.

The service had made demonstrable progress in strengthening its culture. Most staff described improvements in the working environment in recent years. Staff told us senior leaders and matrons were increasingly visible and approachable, which supported a more open culture where concerns could be raised.

This improvement was reflected in the most recent staff survey results, which showed the trust scored above the national average for all seven NHS People Promise elements (The NHS People Promise consists of seven core elements developed to improve the workplace experience) and for Staff Engagement, although Morale was slightly below average. 72.4% of staff said they would be happy with the standard of care provided at the service if a friend or relative needed treatment, compared with 70.9% nationally and 61.7% would recommend the trust as a place to work, compared with 60.9% nationally.

Staff also reported positive experiences of teamwork and support from line managers, with scores continuing to improve and remaining above the national average.

Areas for continued improvement include workload pressures, competing demands on staff time, work-life balance, and staffing levels. The trust continues to address these issues through its workforce and well being initiatives. Overall, these findings indicated that leadership actions had contributed to a more supportive and inclusive working environment.

Internal neonatal staff survey results showed improvement in areas such as sense of purpose and engagement. In response to staff feedback, the service introduced regular “time to talk” sessions, although attendance was variable. Senior leaders, including the matron and deputy matron, also attended daily huddles to maintain visibility and reinforce leadership presence.

However, this positive experience was not consistent across all areas of the service. Some staff, particularly on the LDU, described a reduction in perceived support following changes to coordination roles. Staff told us these changes had increased pressure on the team and impacted their day-to-day working experience. This indicated that, while overall improvements in culture had been made, they were not yet fully embedded across all areas. Leaders needed to ensure that changes to roles and structures were consistently supported and that all staff felt equally supported in their roles.

Following an external review, the service implemented a structured improvement plan with multiple workstreams. This identified key priorities raised by staff and supported a move away from a top-down management approach. A key output was the development of an “ethos charter,” aligned to trust values and expected behaviours, co-produced using staff feedback. This included expectations around teamwork, communication, and managing workplace behaviours constructively.

Work continued to embed these cultural changes through ongoing engagement sessions involving staff from all bands and disciplines. Leadership teams acknowledged that sustained improvement required continued focus on communication, feedback, and visibility.

Support for leadership was provided through peer networks, including collaboration with other children’s matrons. Senior medical leadership, including the clinical director for children’s services, provided oversight of governance processes and attended regular governance meetings, ensuring escalation into divisional leadership structures.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness, and honesty.

Staff consistently described a positive and improving team culture. Across all staff groups, there was strong praise for teamwork, with many describing the unit as supportive and cohesive. All staff we spoke with praised the new matron and deputy matron, highlighting their visibility, approachability and commitment to improving the service. They told us they felt able to speak openly with senior managers and that leadership had become more accessible. The matron and deputy matron won the trust's previous year's staff recognition award.

Staff also valued the focus on development, including the appointment of a Band 7 learning lead and the consistent provision of supernumerary time, which enabled staff to develop their skills. Leaders were described as taking time to understand individual circumstances and career progression, which supported staff well being and retention.

A leadership review undertaken approximately three years ago identified cultural challenges within the service. In response, the matron and deputy matron leadership structure was strengthened, with a focus on improving visibility, communication, and support for staff. Regular engagement opportunities were introduced, including Band 6 and Band 7 meetings, and efforts were made to improve support for staff undertaking management responsibilities. The trust also developed a ‘Growing stronger together’ leadership development and action plan to support leaders’ competencies.

Leadership arrangements had strengthened in some areas; however, there had previously been gaps within the administrative team. Staff told us these were recognised and addressed, with additional leadership support to provide oversight and structure.

While the overall opinion of leadership was positive, there were pockets of concern. Some staff told us they did not always find medical leads to be approachable and felt their concerns were not consistently listened to. This indicated variability in leadership visibility and engagement across professional groups.

Information about the leadership team was clearly displayed in reception areas, which helped parents and families understand who was responsible for the unit and supported transparency.

Staff feedback from the LDU indicated concerns about leadership visibility and understanding of workload pressures. All staff we spoke with expressed that leaders did not always have a clear understanding of the demands within the unit. Staff told us the ward had previously been led by an Advanced Nurse Practitioner who was consistently present on the ward, but this had changed in recent years to a junior consultant model, where support was available on site but not always directly present within the clinical area. Staff felt this reduced the level of immediate leadership oversight and support. We reviewed incident data and could not find evidence of baby harm as a result of these changes. However, leadership needed to improve communication with this team to ensure they understood the reason for changes and could bring the LDU team on board.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up, and their voice would be heard.

Staff told us they felt confident to speak up and raise concerns, and that action would be taken in response. The Freedom to Speak Up (FTSU) service was well embedded within the unit. The FTSU team was attending an upcoming team day to further promote awareness and encourage staff to raise concerns openly. The FTSU team had also attended previous staff events, helping to increase visibility and engagement.

Matrons recognised that continued focus was needed to strengthen the presence and profile of the FTSU function and were actively working to improve this. Staff demonstrated a good awareness of the FTSU team, including how to contact and access support if required.

At trust level, there was a strong emphasis on equality, diversity and inclusion (EDI). A range of staff networks were available, including those for Black, Asian and minority ethnic (BAME) staff, women and carers. These networks formed part of the organisation’s wider culture and engagement strategy. Both the FTSU team and staff networks were represented at trust induction, ensuring new staff were aware of the support available from an early stage. Overall, this supported an open culture where staff felt listened to and supported to raise concerns.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

The service had a range of initiatives to support staff well being. Trauma Risk Management (TRiM) support was available across both neonatal and maternity services, alongside two Professional Nurse Advocates (PNAs) who provided peer-to-peer support. Staff also had access to the trust’s employee assistance programme, which offered confidential support including counselling and financial advice. Additional well being resources included support from the trust’s health and well being team and access to trained mental health first aiders.

The department had developed a network of eight well being champions, including TRiM-trained staff across different bands, including a Band 5. Staff told us they valued receiving support from colleagues working at a similar level, as it felt more accessible and relatable.

There were also systems to recognise and celebrate staff contributions. The staff recognition hub enabled colleagues to give immediate positive feedback to one another and was widely used and appreciated. In addition, the department ran a ‘Star of the Month’ initiative, where staff could nominate colleagues in recognition of their hard work and commitment. These initiatives helped to promote a positive culture and staff morale within the team.

We scored the service as 2. The evidence showed some shortfalls. 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.

Governance processes were slow to progress well-established known issues, for example the pace of change and lack of urgency of the environmental concerns on the High Dependency Unit. The unit was a temporary location in 2016 and was still at the same site. Whilst leaders understood the environment did not meet national standards there was still no business case. Therefore, completion was many years away. The services risk registers did not reflect the need for change or the impact on babies and families. Leaders had false assurances regarding the risks related to using multiple record systems, as ward clerks did not have the chance to report incidents or record concerns and were escalating via informal methods.

However, there were clear governance structures to support oversight and learning. Senior neonatal leaders, including consultants and senior nursing staff, met fortnightly to review multidisciplinary governance issues. These meetings included discussions on long-stay babies, transport activity, deaths and immediate learning from incidents.

A weekly perinatal mortality review meeting was held, attended by senior matrons, the senior medical team and the bereavement team. These meetings ensured detailed review of cases and supported shared learning. In addition, a monthly clinical governance meeting reviewed incidents, audits, complaints, feedback and performance data.

At a directorate level, senior leaders met twice weekly, including representation from medical, administrative and allied health professional teams such as speech and language therapy and occupational therapy. These meetings focused on strategic planning, workforce challenges, and escalation of concerns identified through incidents, audits and performance monitoring. The directorate risk register was reviewed monthly.

Key risks within the neonatal service included nursing staffing levels. Although the establishment was deemed appropriate, vacancies meant shifts were regularly supported by bank and agency staff. The service also operated its own in-house neonatal transport service (SONeT), which was supported by a dedicated governance meeting to ensure safe and effective oversight.

The governance team included a perinatal governance lead, clinical governance nurse, clinical governance lead and clinical governance consultant. This team worked closely with matrons and clinical leaders to ensure effective governance processes across the department. A dedicated perinatal governance role had been introduced to strengthen oversight, drive implementation of the Patient Safety Incident Response Framework (PSIRF), and ensure timely learning from incidents. Staff received live updates when incidents were reported, supporting a responsive and transparent reporting culture. Learning and outcomes were escalated to directorate and divisional leadership teams.

The medical lead also held the role of local safety champion and met bi-monthly with other safety champions across the trust to escalate risks and share learning. Issues identified were further escalated to board-level safety leads, providing assurance that safety concerns were recognised and addressed at the highest level within the organisation.

We scored the service as 3. The evidence showed a good standard. 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.

The service demonstrated a clear understanding of its responsibility to collaborate and work in partnership with other organisations to ensure seamless care for babies and families. Staff shared information, learning and best practice with partner organisations and worked collaboratively to drive improvements across pathways.

Leaders had developed a ‘conversation and engagement plan’ in response to feedback from a local mothers’ action group. This demonstrated a willingness to engage openly with external stakeholders and respond to concerns. Progress and actions were formally monitored through governance structures, including reports to the Integrated Assurance Committee, ensuring appropriate oversight.

The service worked closely with the local children’s hospice, with weekly calls to discuss care coordination, referrals and ongoing support. The in-house neonatal transport service further strengthened relationships with regional partners, as staff frequently worked across organisational boundaries.

There were strong working relationships with paediatric intensive care units (PICUs), including Southampton and Great Ormond Street Hospital (GOSH). Care was coordinated at consultant-to-consultant level to ensure safe and timely transfers where required. For babies requiring specialist interventions such as cardiac surgery, the service stabilised babies prior to transfer to specialist centres, as surgery was not undertaken on site. Families were supported through this process, including opportunities to visit receiving units before transfer, helping to reduce anxiety and support continuity of care.

We scored the service as 3. The evidence showed a good standard. 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 demonstrated a strong and proactive approach to quality improvement, innovation and research. There were a number of ongoing quality improvement (QI) projects, including the development of transitional care pathways. Dedicated leadership for this area included a transitional care consultant and an advanced nurse practitioner (ANP), with regular team meetings held to review progress, identify challenges and implement improvements. The service had also developed competency packages to support parents in administering antibiotics, promoting independence and supporting earlier discharge where appropriate.

The service was working with the Thames Valley and Wessex Neonatal Network to support the development of a standardised infusion. Standardising neonatal infusions establishes fixed, ready-to-administer medicine concentrations rather than weight-based preparations. This practice improves safety by reducing preparation errors and saving time.

Leaders were focused on workforce development and sustainability. The service was developing an apprenticeship programme for nursery nurses to support career progression. Staff recognised that additional training was required to enable nursery nurses, particularly those more familiar with caring for well babies, to confidently care for unwell infants. This demonstrated awareness of skill mix and a commitment to strengthening the workforce.

The neonatal service had an established research culture, supported by a dedicated research team. Ongoing work included reviewing clinical practices, such as the measurement of gastric aspirates and approaches to feeding, as well as improving procedures such as lumbar puncture positioning to enhance comfort and outcomes for babies.

The unit was actively involved in 55 national and international research trials. The unit was involved in several research studies aimed at improving care for premature babies. These included the Baby-NEO Gastric Study, which looked at whether routinely checking the amount of milk left in a baby's stomach before feeds was beneficial; the WHEAT trial, which investigated whether temporarily stopping milk feeds around blood transfusions could reduce the risk of a serious bowel condition called necrotising enterocolitis; the BALLOON study, which explored whether a bacterial spray given under the tongue could help prevent chest infections in extremely premature babies; and the BASE trial, which examined whether giving sodium bicarbonate through a drip was an effective treatment for a condition where there is too much acid in the blood of very premature babies. These studies aimed to improve treatment and outcomes for vulnerable newborn infants.