Royal Lancaster Infirmary

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 Requires Improvement. At this assessment the rating has changed to Good.

Good: This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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 women who used services and wider communities. We found the leadership in maternity services at RLI had worked hard to improve the culture in the department and worked alongside staff to listen and facilitate change. 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. We found this to be the case. However, we saw, and department leaders agreed there was still room for improvement in some areas and this was incorporated in their plans for the future of the service.

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 have a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of women and our communities.

The evidence showed a good standard of staff sharing direction and culture. 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 women and their communities.

There was a Maternity Strategy 2024-2027 which contained objectives relating to the workforce, quality and safety and technology. It also referenced former reports including Kirkup and Ockenden. The strategy highlighted key priorities for its duration including delivering outstanding care and experience, creating a culture where staff could be the best they can, making the best of resources and working in partnership with stakeholders.

Most midwifery nursing staff we spoke with knew there was a service strategy and were able to articulate the vision and future plans for the service including the redevelopment of some maternity services estate to improve experiences for women and their families.

Staff we spoke with told us that local teams worked effectively together to ensure women received the best outcomes. There was a senior leadership and governance structure, which supported the maternity services department. Maternity services were part of a larger directorate including surgical services.

Staff told us they could raise concerns and incidents because they found the trust had a learning culture. Although this had not always been the case, work was ongoing to improve the culture. Most staff told us they were not concerned about raising concerns and reporting that they had made an error because they felt the incident would be reviewed fairly and holistically to identify root causes.

Most staff we spoke with told us there were no concerns about the culture within the different maternity departments however some told us that there were pockets of staff who were not always inclusive and some managers who did not treat all staff equally or who behaved inappropriately. When we looked at the Freedom to Speak Up information we requested, we saw similar examples raised about staff not being treated fairly and inappropriate behaviours from line manager midwives. Senior leaders were working with staff to improve the culture in departments by providing training and having regular 1:1 meetings to address concerns raised.

Staff described feeling positive about changes ahead including building work which made them feel more positive about the future of maternity services once it was complete. 

Staff at all levels told us they felt that senior leadership understood the staffing needs of the maternity services.

We heard that there was oversight of the service and an understanding of what the service needed from a midwifery viewpoint. Staff felt there was transparency and clarity regarding staffing plans for the service.

We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

The evidence showed a good standard of capable, compassionate and inclusive leaders. 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.

There was maternity services representation by 2 non-executive directors at Board level as well and the director of midwifery. This was important because it made sure the Executive Trust Board were sighted at the highest level about any challenges face by maternity services.

Senior leaders had the skills, knowledge and experience to oversee maternity services delivered by the trust. They were appropriately qualified health professionals who understood the challenges faced by maternity services delivered across the trust. They worked together as a senior team to ensure safety and quality of services were at the forefront of service delivery.

During the inspection, staff told us they had no concerns about the behaviours of senior staff. They told us they were able to speak with senior colleagues about any concerns they had about the working environment or perceived risks. They told us senior leaders were professional and credible. Staff also told us that leaders were accessible.

Most staff told us they felt supported by their immediate line managers and felt able to speak to the shift managers about any concerns or personal issues. However, a small number of staff expressed that they did not feel supported by some managers, particularly in terms of personal development and support. They told us some managers could be dismissive and unhelpful whereas others were helpful and encouraging.

We were provided with assurance that leaders took incidents seriously and investigated them as fully as appropriate.

The evidence showed a good standard of staff feeling supported to speak up. The service fostered a positive culture where women felt they could speak up and their voice would be heard.

The trust had a Freedom to Speak Up (FTSU) Policy which was easily accessible to staff, explained roles and responsibilities and provided details of support available to individuals who spoke up. We reviewed the policy, and it was due for review in December 2025, therefore within date.

The trust also had a whistleblower policy. We reviewed the policy and it was due for review in December 2025, therefore within date. It was accessible to staff and explained the roles and responsibilities of those involved in whistleblowing. It also provided information about support available to people who whistle blew.

Staff were encouraged to speak up within the maternity service as part of an open and supportive learning culture.

The trust had an established Freedom to Speak up process where staff could raise concerns if not addressed through the line management route. Staff were aware of this service and some told us they had followed this route in the past. Staff we spoke with had not raised any recent concerns with the freedom to speak up guardians.

Some staff we spoke with told us they felt confident to actively speak up and raise concerns without fear of detriment or reprimand. However, this was not the case for all staff, some of whom had concerns about upsetting department managers by speaking up. However, some staff had chosen to use the FTSU route to raise their concerns. These concerns related to inappropriate behaviours such as bullying, treating women unfairly and making derogatory comments about patients and colleagues.

We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.

The evidence showed some shortfalls. The service did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff completed equality, diversity and human rights training and we saw the completion rate was 97% average across all disciplines for Royal Lancaster Infirmary. This was better than the trust target of 90%, at the time of inspection.

The trust has a strategy in place for Equality and Diversity called ‘Positive Difference Inclusion & Diversity Strategy 2021 – 2026’. It lays out the trust’s commitment to fostering an environment where everyone feels that they belong, and where bullying, harassment and discrimination are not tolerated.

We reviewed the staff survey results 2024 for the division. This included the maternity service and findings showed there was improvement required with workforce equality. Data showed that only 56% of staff felt that the organisation acted fairly for career progression. This had reduced from 2023 (61%) and was slightly worse than the whole trust comparator (60%). Data showed that only 44% of staff believed that the organisation had made reasonable adjustments for their disability. This showed improvement from 2023 (40%) but was worse than the rest of the trust (72%)

However, findings showed that 93% of respondents had not experienced discrimination from managers, team leaders or other colleagues. This was similar to the rest of the trust and comparable to results from the 2023 survey.

The survey data showed that 92% of staff had not experienced harassment, bullying or abuse from managers. This was similar to the rest of the trust and showed improvement from 2023.

The NHS survey 2024 included trust specific data on Workforce Race Equality Standards (WRES) and Workforce Disability Equality Standards (WDES). This data is representative of the trust as a whole and not specific to maternity services.

Data showed that 61% of white staff and only 49% of staff from other ethnic groups believed that the organisation provided equal opportunities for career progression or promotion. The percentage of staff experiencing discrimination at work from a manager or other colleagues in the last 12 months was higher for staff from other ethnic groups (20%) compared to white staff (7%).

Findings showed that 55% of staff with long-term conditions or illnesses and 61% of staff without long-term conditions or illnesses believed that the organisation provided equal opportunities for career progression or promotion.

We saw that leaders took action to review and improve the culture within the service in the context of equality, diversity and inclusion. We spoke with external partners and stakeholders who told us that the trust was fully engaged with the recruitment of internationally educated midwives.

We have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

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.

Managers we spoke with explained policy reviews, ratification and distribution processes were effective and timely. We saw much improvement in policies and guidelines since our last inspection, of the documents reviewed we saw that all were in date and referred to relevant guidance and legislation, and a robust process was in place to sustain this.

Risks identified within the service across the trust were documented on the risk register, and rated as red for extreme, amber for high, yellow for moderate and green for low risk. We reviewed the risk register from 30 July 2025 and saw 11 risks documented. The 3 highest risks for the service were all relating to the Royal Lancaster Infirmary site. As we spoke with staff, they were able to discuss the risks with us. The risks related to the fabric of the building, delays to postmortem results carried out by a different organisation and the temporary closure of bespoke bereavement facilities for women and their families. The trust had appropriate mitigation in place to reduce their impact.

All risks entered on the register were regularly reviewed and reported on through the trust governance structure for assurance. We were assured leaders were fully aware of all key risks within the service. We were also assured there was suitable and sufficient oversight of risks and their potential impact on the safety of women and their babies.

The risk register was managed not just through escalation of concern but through themes, trends, and audit. They held a risk clinic for the division which was chaired by the head of midwifery and produced a monthly report. Leaders felt confident that staff understood risk and the risk clinic was participative and included the risk owners.

An eLearning module was available on risk management for all staff and any member of staff could add a risk to the register.

Senior leaders ensured that key clinicians involved in governance had clear roles and responsibilities.

We reviewed the trust’s compliance with the Clinical Negligence Scheme for Trusts (CNST) maternity incentive scheme. Data provided by the trust showed that the service was compliant with all of the 10 safety actions for year 6 and on track to meet all safety actions for year 7, with their next assurance visit scheduled for 19 September 2025.

The service leads said they had some internal areas to work on such as training with the anaesthetics team and compliance data, suitable training dates being identified within the team and neonatal compliance on resuscitation was also being worked on. These were monitored through quality and safety groups.

Staff told us that managers were happy to support them with clinical duties if they required them. However, this was not often required due to adequate staffing and shift planning ahead of time.

Leaders told us that the restructured leadership and operating model for the Surgery and Families Division had improved collaboration and communication. The director of midwifery and neonates attended the trust board of directors’ meetings to present updates on maternity and neonatal services. They were supported by the board level safety champions. Senior leaders attended trust management team meetings chaired by the chief executive and could access advice and support from the executive team.

Leaders attended quality assurance meetings, mortality governance meetings and clinical governance meetings that included reviews of incidents. They also attended trust wide safety and staffing meetings. Staff and managers attended bi-monthly maternity services meetings and held separate unit meetings.

The service used the Perinatal Mortality Review Tool (PMRT) and multidisciplinary meetings were held to review and monitor stillbirths, fetal loss, neonatal and post-neonatal deaths. The service had a dedicated lead and there was consultant presence at PMRT meetings. The service monitored compliance against PMRT requirements as part of the maternity incentive scheme and the service had achieved compliance with this.

The service had a quality and safety lead who had implemented new systems to review clinical incidents and identify learning. There was also a risk lead who worked together with consultants to support quality and safety.

The service had maternity and neonatal processes in place following an adverse outcome that was clearly demonstrated in flow charts. For example, stillbirth, hypoxic ischaemic encephalopathy (HIE), neonatal death and emergency hysterectomy.

The service had regular assurance visits by the LMNS (Local Maternity and Neonatal System) and MSSP. Leaders reported that feedback was positive, and partners had acknowledged progress made by the service. At the time of our inspection, the service was due for their next assurance visit the following week, which was postponed awaiting the inspection outcome.

We saw that the service had made significant improvements since our last visit including governance. However, we asked service leads how they were assured of the sustainability of the service once all improvement work is completed and some finances will end. They told us they had plans in place which included no cuts to staffing and were focussed on patient safety. Therefore, they had plans that looked at reducing a number of other things.

There was a cost improvement programme under the waste reduction programme. The leads were clear that there was no disinvestment to maternity. The director of midwifery had presented a paper to the board about Birthrate Plus staffing and it was agreed that there would be no reduction in staffing. There was a financial stewardship programme which encouraged everyone to be more financially aware. They acknowledged that it was a tough ask, but they were working tirelessly as a division to save money and reduce inefficiency. The biggest challenge was separating the maternity budget from the obstetrics budget. There had been a specific ask of the finance team to work on this.

We understand our duty to collaborate and work in partnership, so our services work seamlessly for women. We share information and learning with partners and collaborate for improvement.

The evidence showed a good standard of partnership working. The service understood their duty to collaborate and work in partnership, so services work seamlessly for women. They share information and learning with partners and collaborate for improvement.

Leaders engaged with external stakeholders – such as commissioners and Healthwatch.

Most external partners and stakeholders spoke positively about the trust’s collaborative approach. This included regular partnership working LMNS, MSSP, MNVP and MNSI. The service also partnered with Healthwatch to engage further with women and families within the community.

Partners told us that leaders collaborated well and were responsive to improvements that had been identified by MNSI, perinatal mortality reviews and external reviews. The service had regular meetings with LMNS and various stakeholders to provide assurances, discuss updates and share information. There were also multidisciplinary assurance visits that provided further observation and oversight. Partners told us that staff and leaders were very engaged during assurance visits.

Leaders had commissioned independent reviews for fetal medicine and category three caesarean sections in response to themes from incidents. Partners told us findings from independent or external reviews were shared with them to enable monitoring.

In line with national requirements, the service had entered the Maternity Safety Support Programme (MSSP) in 2022 due to concerns regarding maternity care. This included partnership with an allocated maternity improvement advisor from NHS England.

The service worked with MNVP who engaged with women in the community and in hospital. Feedback from MNVP was shared with leaders and the board through monthly reports. The reports had an overview of engagement activities that had taken place during the previous year and examples of feedback from women. However, we looked at monthly reports from November 2024 to February 2025 and they did not show what changes had been made or specific actions that had been taken in response to feedback.

The MNVP lead received two days of funding a week funded by the integrated care board (ICB). Some staff and partners told us that further funding and collaboration with members of the MNVP was an area that needed improvement and more timely actions in response to feedback from women.

The electronic patient record system allowed the service to share any alerts with other NHS trusts if a woman had been assessed as having complex needs. For example, mental health or safeguarding needs. This meant staff could track women who were accessing multiple services.

We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for women. We actively contribute to safe, effective practice and research.

The evidence showed a good standard of learning, improvement and innovation. 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.

All new starters and newly qualified midwives undertook their preceptorship in what was described as ‘a psychologically safe environment’. The service had established links with students and schools to help those thinking of a career in maternity or starting their career in midwifery.

We saw that there were quality improvement (QI) projects taking place across the service. Staff had reported improvements following a QI project into the acutely unwell. This included improvements in emergency drill simulations, equipment checks, and wound infection management.

We spoke with external partners and stakeholders who told us the service was fully engaged in regular quality assurance meetings and patient safety learning groups. This included shared learning and the impact from quality improvement projects.

Midwives carried out research as part of their continuing education. They recruited women to participate in research studies with the National Institute for Health Research (NIHR) so women could access new and innovative treatments. These midwives monitored and followed up women who had voluntarily participated in research studies. Studies included the role of self-management of raised blood pressure after birth, ways to help prevent early stillbirth and prevention of anaemia in pregnancy. Midwives had presented at a national research conference and shared examples of positive outcomes for women such as improved blood pressure.

Staff told us that case review meetings involved staff and family more than they did previously. They told us that standard safety messages were shared in various formats such as social media and QR codes. We observed newsletters from February and March 2025 that showed safety messages were shared with staff. For example, an alert for staff to complete the Post Partum Haemorrhage (PPH) proforma for all women who sustain a blood loss of over 500mls.

The chaplaincy team also provided support for staff following trauma in addition to supporting women and families. The team provided memorial services throughout the year to remember lives that were lost and the bereaved families.