Furness General 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 Requires Improvement. At this assessment the rating has changed to 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 FGH 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.

The evidence showed some shortfalls. The service did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The trust was one of 122 in the Acute and Acute & Community Trusts benchmarking group for the 2024 NHS Staff Survey. The trust response rate was 41%, which was an improvement on previous years, however just below the 49% average seen nationally. The results of the NHS Staff Survey are measured against the seven Women Promise elements and against two of the themes reported in previous years.

Trust scores were similar to or below the national average for all Women Promise elements and themes in 2024. Statistical significance testing was carried out on all Women Promise elements and theme scores from 2024 and 2023, to determine if a result is likely due to chance or can be attributed to a specific cause. All 2024 scores were found to be significantly lower when compared to results from 2023. The service leads had implemented actions following those results in order to make improvements.

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 did know there was a service strategy and were able to articulate the vision and future plans for the improvement of 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 worried about raising concerns and reporting when they had made an error because they felt the incident would be reviewed fairly and holistically to identify root causes. 

Staff feedback about the culture within the maternity service was much more positive since our last inspection. Staff were positive about the department and its leadership team. They told us they could speak to leaders about difficult issues and when things went wrong. Staff told us that the culture within the service had improved and that they felt valued and proud to work there. Staff told us that morale was better and they felt supported by senior leaders. Staff said that the service was now much more focused on learning from incidents and felt encouraged to incident report.

Staff described feeling apprehensive about potential changes to the ward model, however they were all happy to see how it worked and felt confident to give feedback if they did not find that it was a positive change for women and families.  

We reviewed the service action plan in response to the Maternity Incentive Scheme and Saving Babies Lives Care Bundle and saw the service exceeded the national trajectories set to demonstrate ongoing compliance and improvements with all six elements of the bundle. 

Staff at all levels told us they felt that senior leadership understood the staffing needs of the maternity services. At the time of our inspection, the FGH maternity team had recruited to all vacancies, but there were still gaps until the newly qualified staff joined the team in September following financial input to improve the workforce since our previous inspection.

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

The evidence showed a good standard. 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.

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.

The maternity service sat within the Surgery and Families Division at the trust. The service had restructured and appointed new senior leaders since our last inspection to include a range of expertise and experience and worked as a quadrumvirate with surgery. The maternity leadership team was made up of a Director of Midwifery, 2 heads of midwifery, a Consultant Midwife, a Quality, Safety and Assurance Lead and 3 matrons. The leadership team all worked across all 3 sites apart from 2 site based matrons.

Managers we spoke with explained how the leadership model promoted improved teamwork, communication and set out a clearly defined structure of leadership, responsibilities and ownership. Leaders we met were committed to improvement of the service. Leaders had also identified, prioritised and managed the risks associated with the lack of effective governance processes throughout the service that we found at our last inspection.

The service had practice development midwives to support multidisciplinary training and competencies. These midwives liaised with managers to monitor and ensure training compliance.

Partners told us that leaders were very responsive to external reviews, professional, supportive and engaged.

There was maternity representation by a non-executive director at Board level. This was important because it made sure the Executive Trust Board were sighted at the highest level about any challenges faced by maternity services.

Feedback from staff we spoke to about management was overwhelmingly positive. Staff told us that managers and senior managers were supportive and took prompt action to help them resolve issues. However, they sometimes felt that there could sometimes be a lack of communication about changes to the service, which meant that they didn’t fully understand the rationale at times.

Staff said they felt supported by senior managers and felt they promoted an open and transparent culture. They also felt supported in terms of development as they were offered development opportunities when they showed an interest. For example, band 7's were being up skilled at the time of our inspection to take on some of the matron responsibilities while they were absent. Once the matrons return to normal duties, the band 7's were offered the opportunity to continue to take on some of those responsibilities on a rota basis to aid their own development.

Some staff we spoke with told us they knew the service leads and felt comfortable to raise any concerns and that they would be addressed in a timely way.

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

The evidence showed a good standard. 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 along with the whistleblower policy, which were in date.

The whistleblower policy was accessible to staff and explained the roles and responsibilities of those involved in a whistleblowing. It also provided information about support available to women who chose to speak up.

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.

We met with the freedom to speak up guardian during our inspection. The trust had a full time freedom to speak up guardian and a part time. There were also numerous champions across the trust. The freedom to speak up service was well utilised across the trust, however we found that there had been no contact from maternity staff and most staff were unaware of who they were. Staff didn’t feel that they required the service due to the positive support from professional midwifery advocates.

Although staff weren’t aware of who the individual members were, they were clear about the role of the freedom to speak up service and it was promoted widely across the trust via newsletters, emails, social media and policy. Staff knew how to find their details should they wish to use this route. Staff could contact the guardians via anonymous forms or in person.

They aimed to do some further work with the service to raise their profile and offer their service as an alternative to the PMA route.

All staff we spoke with told us they felt confident to actively speak up and raise concerns without fear of detriment or reprimand.

The results from the National Maternity Survey 2024 showed the trust scored ‘About the same’ as other trusts for women being able to raising concerns.

Patients and staff could meet with members of the provider’s senior leadership team to give feedback. For example, women and carers had opportunities to give feedback on the care they received in a manner that reflected their individual needs. Women were given the opportunity to meet with a staff member to discuss their birthing experience, especially if the experience was not what they had wanted or expected. This gave women the opportunity to ask questions and understand why and gave the trust the opportunity to learn from experiences and make improvements.

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 94% for Furness General Hospital Maternity. This was better than the trust target of 90%, at the time of inspection. 

The trust had processes in place to make reasonable adjustments to support staff in order for them to carry out their roles however, some staff told us these were not always implemented to support them. 

There were maternity safety champions who had a broad spectrum of representation including gender, ethnicity and disability. 

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 also 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.

The trust had an equality and diversity policy, and staff attended mandatory equality and diversity training.

The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and 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, which were 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. Furness General Hospital risks were rated either yellow or green. These included risks on infection control and equipment maintenance. Ward 1 was the main access route to South Lakes Birth Centre from the main hospital site and this was identified as a risk in regard to privacy and dignity of patients. This was under review to identify alternative access routes.

All risks entered on the register were regularly reviewed and reported on through the trust governance structure for assurance. We were clear how the trust assured itself that leaders were aware of all key risks within the service and had sufficient oversight of risks and 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.

There was a focus by senior leaders that they had assurance 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 with the Lancashire and South Cumbria Integrated Care Board. This scheme is designed as an incentive to support the delivery of safer maternity care. 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 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 was completed and some finances will be required to end. They told us that they had plans in place which included no cuts to staffing and were focused 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 will 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.

Their biggest challenge was the maternity budget being intertwined with gynaecology, therefore there had been a specific ask of the finance team to separate budgets.

The evidence showed a good standard. 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.

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 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.

MSSP had worked closely with senior leaders to focus on three key areas; leadership, clinical pathways and governance. The service had an assurance visit in January 2025 from MSSP and an exit plan had been submitted following continued improvements within the maternity service. The exit plan consisted of six criteria and had been supported by an overarching perinatal improvement plan. The exit criteria included actions to strengthen the maternity leadership structure and maternity governance team structure. It also included the development of a maternity strategy, vision, and values. A review meeting had been scheduled for May 2025 to discuss progress and agree on the next steps. 

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. 

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 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. 

Individual midwives undertook research projects as part of their continuing education and 3 midwives had recently applied for a NIHR, Senior Midwife, Building a Research Culture secondment programme. However, participation in multi centre maternity trials and research is facilitated through the Trust Research and Development department. This meant that women could access new and innovative treatments. Research 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. Research 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.  

Staff told us they received emails asking for their opinions and ideas towards innovation and change.

The service participated in a national NHS staff award scheme that focused on innovation and recognition of staff that went above and beyond in their role.