St Helier Hospital and Queen Mary's Hospital for Children

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver safe, integrated, person-centred, and sustainable care, and to reduce inequalities.

At our last assessment we rated this key question requires improvement. The service was in breach of good governance because it did not always operate effective governance processes throughout the service and with partner organisations to maintain clear oversight of maternity services and mitigate risks to women and babies. Since then, the service has made improvements and is no longer in breach of this regulation. This was because the service now had improved governance processes, and leaders were aware of key risks within the service and took appropriate actions to manage and mitigate them. As a result, the rating for this area improved to 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.

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

The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. The maternity services followed the trust vision and strategy. The trust vision for 2023-2028 was “to provide outstanding care, together”. The strategy to accomplish the vision was set out by the CARE objective:

• Collaboration and partnership
• Affordable services, fit for the future
• Right care, right place, right time
• Empowered, engaged staff

However, at the time of the assessment, the maternity service was working to produce a St George’s, Epsom and St Helier University Hospitals and Health Group wide maternity and neonatal strategy. This was following a recommendation from a trust commissioned independent review of the maternity governance in 2024. The plan was to develop this strategy with staff, women and external stakeholders, with a completion date of November 2026. The senior leadership team had communicated the service vision, strategy and values to frontline staff. This helped staff translate goals into daily actionable practices, foster a culture of safety and increased staff engagement.

The maternity vision and strategy were focused on the sustainability of services and aligned to local plans within the wider health economy. Leaders and staff understood and knew how to apply them and monitor progress. Staff could explain how they were working to deliver high quality care for women, babies and their families through various cultural initiatives, such as the cultural awareness training sessions for multidisciplinary staff.

Staff felt supported, respected and valued. Staff were passionate about the care and service provided for local women. They were proud to work in the service and of the improvements made since the last inspection. The trust celebrated staff success and contribution through various ways, such as shout-outs in the staff newsletter and held a virtual improvement celebration event in June 2025. The staff were welcoming and helpful, spoke positively about the service and were passionate about their role. The 2024 staff survey result showed that 63% of midwives would recommend the trust as a place of work, against 62% trust average. This was an improvement from the trust average and the previous survey result.

The senior leaders carried out a trust wide maternity staff survey to understand the culture within the trust. Findings showed that only 38% of staff felt teams dealt with disagreements constructively, 17% of staff never or rarely felt frustrated at work and only 43% of staff felt their working relationships were unstrained. The service developed an action plan in response to the findings and recommendations. This highlighted that there was still room for improvement in the service's culture. The service had also undertaken several initiatives with multidisciplinary staff to improve the culture of the staff, which included training and engagement meetings.

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.

The trust maternity services were provided across two sites; St Helier Hospital and Queen Mary’s Hospital for Children, and Epsom General Hospital. The maternity service was part of the women’s and children's division, and the trust had a defined leadership structure across site. The maternity leadership team consisted of the director of midwifery, the divisional medical director, the associate director of neonates and paediatrics, who were also the service safety champions for the trust and the division, and the divisional director of operations. They were supported by the head of maternity, consultant midwives, and matrons. The service was also supported by the board maternity safety champions and non-executive directors. There were clear lines of reporting from the site leadership team through to the quadrumvirate and the board. The senior leaders reported good support and access to the trust board and safety champions.

Leaders had the skills, knowledge and experience to perform their roles. Leaders understood and managed the priorities and issues the service faced. They had oversight and were aware of the risks within the service and were able to describe the mitigations and action plans in place. This was an improvement since the last inspection. They could explain clearly how the teams were working to provide high quality care.

Leaders were visible and approachable in the service and for women and staff. The majority of multidisciplinary staff told us that leaders were visible and approachable; however, some staff said some leaders were not visible. The board safety champions held quarterly staff engagement meetings and walkarounds. The service conducted monthly board safety champion meetings which was attended by board safety champions, trust level leadership and service level leadership. The director of midwifery also held regular engagement meetings with the staff. Data showed the director of midwifery held 4 engagement meetings with staff in July and October 2025. The service also held an appreciative inquiry meeting for band 7 midwives in June 2025 with the aim of strengthening team culture.

Leadership development and career progression opportunities were available for staff. Leaders supported staff to develop their skills and take on more senior roles such as a rolling labour ward coordinator secondment for band 6 midwives. However, some band 7 midwives told us they wanted more managerial responsibilities to help their development. It was unclear if they had asked for these or if they were not available to them.

Leaders were aware of the culture within the service and how this could affect the quality of people’s care. This was addressed quickly through engagement meeting and focus group and resulted in the development of action plans. Leaders understood how health inequalities affected treatment and outcomes for women and babies from ethnic minority and disadvantaged groups in their local population. The service had a service improvement and transformation lead midwife, who worked closely with women from the local population and stakeholders such as the local maternity and neonatal voices partnership (MNVP). The information gained through various initiatives was then fed back to leaders to improve the service.

Staff and Leaders had considered and understood national maternity specific recommendations such as the Ockenden report to drive improvement in the service.

Not all staff felt they could speak up and their voice would be heard.

Staff at all levels we spoke with during the assessment reported feeling comfortable speaking up. Staff told us they were encouraged to raise concerns without fear and promote the value of doing so. Staff we spoke with were confident that their voices would be heard.

However, the 2024 NHS staff survey result for the cross-site maternity services showed some areas of improvement. Data showed that 51% of staff felt safe to speak up about anything that concerns them in the organisation, which was below the trust average of 59.5%. Also, 42.4% of staff felt the organisation would address any concerns raised, which was below the trust average of 49.6%. Data also showed that 39.3% of staff reported that their immediate managers asked about their opinion before making decisions that affected their work. This was against the trust's average of 58.3% and was a 3.5% decline in performance from the previous year. The service had developed an action plan to drive improvement and improve staff experience around their wellbeing and service culture.

The service had a freedom to speak up guardian and champion, and staff knew how to access them for support. We observed the service had posters and flyers about the speak up guardian. Staff also had access to the professional midwifery advocates (PMA) who staff described as supportive and approachable.

Women, relatives, and carers knew how to complain or raise concerns. Managers investigated complaints, identified themes and shared feedback with staff. Staff knew how to acknowledge complaints and women received feedback from managers after the investigation into their complaint.

The trust maternity services received 10 complaints between June and August 2025, which mostly related to care during birth. In the same period, the trust maternity services received 91 contacts from the patient advice and liaison service (PALS). The top themes were around appointment and referral, notes and administrative request, positive feedback and home birth provision. The service complaints’ tracker showed that the service had 6 open complaints, 4 were currently under investigation and 1 investigation reports was waiting for sign off. However, the service had 1 overdue complaint which had been investigated but not completed within the agreed time frame and was waiting for a final sign off.

Women and their families could complete the friends and family test (FFT) on the unit. The trust maternity FFT data from May to November 2025 showed 78% of women had a very good experience, 17% experienced good care, 3% experienced poor care and 2% reported experiencing neither good nor poor care. The trust did not provide the response rate from the survey. The most common themes in the women who experienced poor or neither good or poor care were; delays in care, building, staff attitude and communication. Some of the positive feedback received from women relating to the service were around positive overall experience, compassionate care, staff kindness and excellent staff and service. However, the service did not highlight any work being done in these specific areas.

Women and staff could meet with members of the provider’s senior leadership team, MNVP and safety champions to give feedback. The MNVP shared feedback received from women to senior managers to drive improvement. An example of positive feedback received included reports that women had a great experience at the birth centre, staff were professional and they actively personalised care to women. Areas of improvement identified from feedback received was around induction of labour and options around the place of birth. This has resulted in quality improvement projects around induction of labour and a review of homebirth provision.

Managers and staff had access to the feedback from women, families and staff and used it to make improvements. Learning from feedback was used to improve the service. Changes and improvements made to the service following feedback from the FFT results were shared through the ‘You said we did’ initiative. Examples of changes made included redesigning of the maternity website to include information for service users around all aspects of the service. The digital midwife was also working with the electronic record and administration teams to improve women’s access to their appointment information on the electronic record system.

The service was working towards embedding an inclusive and fair culture by improving equality and equity for people who work for them.

Leaders were working towards ensuring that staff and leaders were representative of the population of people using the service. The staff we observed on site during our assessment were broadly diverse and representative of the population of people using the service. However, the Maternity and Neonatal Voices Partnership (MNVP) had highlighted to senior leaders the need for greater diversity in representation among staff and the MNVP group to better reflect the local population and improve engagement with seldom-heard groups such as people from ethnic minority group, women with disabilities or living in areas of deprivation.

The NHS staff survey 2024 included trust specific data on Workforce Race Equality Standards (WRES) and Workforce Disability Equality Standards (WDES). The data was representative of the trust as a whole and not specific to maternity services. The finding showed 24% of white staff and 22% of staff from other ethnic groups had experienced harassment, bullying or abuse from staff in the last 12 months. Findings also showed that 55% of white staff believed the organisation provided equal opportunities for career progression or promotion, while only 51% of staff from other ethnic groups felt the same.

Findings from the trust workforce disability equality standards question showed, 16% of staff without long-term conditions or illnesses had experienced harassment, bullying or abuse from other colleagues in the last 12 months. Whilst 25% of staff with long-term conditions or illnesses had. Findings also showed that 54% of staff without long-term conditions or illnesses believed the organisation provided equal opportunities for career progression or promotion. Whilst only 48% of staff with long-term conditions or illnesses felt the same. These findings showed a slight improvement from the trusts 2023 NHS staff survey data however, still identified room for improvement.

Leaders acted to continually review and improve the culture within the service in the context of equality, diversity and inclusion. The service had a cultural improvement plan in place following the appropriate cultural inquiry held in 2024 for staff following concerns received by senior leaders. The cultural improvement themes identified included areas such as tensions across service areas, fairness and preferential treatment, human resources (HR) processes and support, communications, supervision and development and behaviours. As part of the improvement plan, leaders held various staff engagement meetings such as band 7 engagement meetings and student midwives’ forums. All staff we spoke to felt respected, supported, and valued.

Leaders took action to prevent and address bullying, discrimination and harassment at all levels and for all staff. Leaders actively reviewed policies and procedures to ensure structural and institutional discrimination and bias were tackled to achieve a fair culture.

The service held a cross-site student midwives forum between February to May 2025. This was following issues and concerns raised by the student midwives through their clinical placement facilitator (CPF) team around microaggression, racism, incivility, and inequality in training in clinical practice. The meeting had included student midwives from ethnic minority groups and was chaired by the service improvement and transformation lead midwife with representation of midwives from ethnic minority groups. Findings from the forums was shared with leaders, the university and staff with the aim to improve the student experience. The service planned on undertaking a follow-up forum in February 2026, which will be specific to students from the ethnic minority groups. Student midwives we spoke with during assessment told us they felt supported and reported a good culture in the service.

The service also offered staff interview preparation and coaching for staff who required additional support with job interviews. Data showed that 8 staff had taken up the coaching and interview preparation support. Senior managers planned to review the coaching and interview support, and their impact on success rates, in 2026.

The MNVP held a focus group with people from ethnic minority groups and created ‘the happiest day of your life’ video from the feedback received from women, to help improve and drive cultural awareness sessions and discussions with staff and senior leaders.

The trust maternity services had an equality, diversity and inclusion framework and had enrolled in an anti-racism framework programme in December 2024 and established an anti-racism implementation advisory group in March 2025. The group held meetings, however it was unclear how often these were. The meeting covered multiple agenda items such as; staffing issues and information from various ethnic minority groups forums.

Leaders ensured there were effective and proactive ways to engage with and involve staff with protected equality characteristics. The trust supported various staff equality networks under their ‘People Only Succeed If Talent Is Valued Equitably’ (POSITIVE) initiative.

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 acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Leaders operated effective governance processes, throughout the service and with partner organisations. The governance team was fully staffed at the time of the assessment to support governance. The team comprised of a lead midwife for governance, an education practice development midwife, an audit and compliance midwife, a clinical practice facilitator, a clinical risk midwife, an interim recruitment and retention midwife, and a fetal monitoring lead.

Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service. The service held regular service and cross-site divisional meetings, which fed into the trust board report. This included the perinatal quality governance meetings, board safety champions meetings, senior leadership meetings and women’s health quality meetings.

There was a clear framework of what must be discussed at ward, service or division level team meetings, to ensure that essential information such as learning from incidents and complaints, performance data, and policies, were shared and discussed. Governance meetings were well attended by leaders and multidisciplinary staff. The MNVP chair also attended some of the governance meetings but not all due to limited hours worked per week. At the time of the assessment, the trust had a vacancy for another co-chair which was funded by the Surrey Heartlands Integrated Care System.

The service collected reliable data and analysed it. They had a maternity dashboard of performance, which was accessible to senior managers and shared with the local maternity and neonatal system (LMNS). Key performance indicators such as bookings, number of births and stillbirths were displayed for review and managers could see other locations’ data for internal benchmarking. Managers also had access to the LMNS dashboard and could benchmark their performance with other local NHS trusts. The trust was not an outlier for neonatal deaths between June and October 2025.

The trust submitted data to Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK) as required. The MBRRACE- UK 2023 perinatal mortality report showed that the trust was average for stillbirth and neonatal death rates when compared with similar trusts for all deaths. However, the report showed that when congenital abnormalities were excluded, the trust stillbirth rate was more than 5% higher than similar trust. The trust undertook a comprehensive review of the stillbirth cases and noted that in 17% of the cases, the women had not received care with the trust to the point of baby death. The trust reported no maternal deaths from December 2024 to November 2025. The last recorded maternal death at the trust was reported in 2021.

Data or notifications were consistently submitted to external organisations as required such as the maternity and newborn safety investigations (MNSI). The service submitted all qualifying cases to the MNSI. The trust had referred 1 qualifying case to the MNSI in the last 6 months, which had been accepted and being investigated.

The trust submitted data to the maternity services data set (MSDS). The MSDS is a national dataset that captures patient-level information from the booking appointment until discharge to improve clinical care and safety and reduce health inequalities.

The September 2025 women’s health quality meeting minutes showed the trust was currently a national outlier for postpartum haemorrhage (PPH) over 1,500mls and the service had updated their guideline around medicine management to improve outcomes. The maternity dashboard showed that from June to November 2025, the overall PPH rate was 3.51%, however, the trust noted an increase in the PPH rate from August to November 2025 compared to June and Nov 2025. PPH is one of the leading causes of maternal mortality, and a high rate of PPH can impact maternal health and future pregnancies. This resulted in PPH been made one of the top priorities in the service to reduce the high PPH rate and improve women’s outcomes and experience. The service had low rates of third-degree tears and reported an average of 1.9% from June to Sept 2025.

Information from the maternity dashboard was in an accessible format, and was timely, accurate and identified areas for improvement such as PPH.

Data showed that the trust was 96% compliant with the Saving Babies' Lives Care Bundle (SBLCB) version 3 as of 23 October 2025. Action plans were in place and monitored to address areas of non-compliance.

The service held monthly multidisciplinary perinatal mortality review tool (PMRT) meetings and used the PMRT to review care and deaths that occurred within the service. The service also produced a quarterly report of PMRT data to the trust board and developed an equality diversity inclusion workstream to address health inequalities identified from these reviews.

Staff had implemented recommendations from reviews of deaths, incidents, MNSI and complaints. This included updating the induction of labour guideline around fetal monitoring criteria following an external incident review. A new guideline on the identification and management of uterine inversion was implemented in March 2025 following a uterine inversion incident investigation. This was an improvement from the last inspection.

The trust was compliant with the clinical negligence scheme for trust (CNST): maternity incentive scheme (MIS) year 6. This was an improvement from the last inspection. The MIS is a financial incentive programme designed to enhance maternity safety within NHS trusts. It rewards trusts that can demonstrate they have implemented a set of core safety actions. At the time of the assessment the service had submitted their evidence for year 7 and were awaiting confirmation of compliance.

Managers and staff carried out a comprehensive programme of repeated local and national clinical audits to check improvement over time. The audits were sufficient to provide assurance and staff acted on the results when needed.

The cross-site maternity risk registers included 14 open risks related to the service at the time of the assessment. This included: ligature, triage line, lone working, maternity block lifts, staffing/training, storage of cardiotocograph (CTG). Staff maintained and had access to the service risk register. The register included the risk ID, the date the risk was added, a description, the current risk rating, the allocated owner, the review date and the controls in place. The risk register included the risks we identified during the assessment, which provided assurance that leaders and staff were aware of the risks and had mitigations in place. This was an improvement from the last inspection. Staff knew the top risks in the service and received updates about the risk register via the patient safety newsletters. Staff concerns matched those on the risk register.

Staff followed up-to-date policies to plan and deliver high quality care according to evidence-based practice and national guidance.

The service had plans for emergencies to ensure continuity of the service– for example, adverse weather or a flu outbreak.

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.

Staff and leaders were open and transparent, collaborated and engaged with external stakeholders – such as commissioners, the local maternity and neonatal system (LMNS), maternity and neonatal voices partnership (MNVP) and Healthwatch.

Staff and leaders engaged with people, communities and partners to share learning with each other that resulted in continuous improvements to the service. Staff, women and their families could meet with members of the provider’s senior leadership team and MNVP to give feedback. We saw evidence that leaders and MNVP listened to their feedback and took actions to drive improvement and women experience.

Leaders understood the needs of the local population and worked with the local maternity and neonatal voices partnership (MNVP) to contribute to decisions about care in maternity services. Service leaders had built meaningful relationships with the MNVP and encouraged them to attend maternity meetings. The MNVP had regular meetings with the trust and bi-monthly MNVP forums and had easy access to the senior leadership team to escalate any concerns promptly.

The MNVP held regular online listening events, coffee mornings, mosque visits, walk the patch, focus groups with women with disabilities and those from ethnic minority groups. They had also collaborated with local organisations to engage and support fathers through outreach and drop-in services at maternity centres and community venues. They provided group and one to one peer support to fathers and supported them to access support in the community. This included supporting and providing information to new and existing fathers around parenting and support with dealing with anxiety, stress and mental health awareness. The MNVP was developing a video walk-through of maternity sites to improve patient understanding and experience.

The birth centre had an active social media page and engaged with teenage mothers in the community and some doulas, to improve service provision for women who accessed the unit including those under the out of care guidance pathway. The birth centre midwives and the MNVP chair held weekly ‘Ask a midwife Mondays’ sessions for women who were considering using the birth centre. At the time of the assessment the midwives and MNVP were planning to introduce a weekly Doula morning. The service is enrolled in the maternity safety support programme (MSSP) and actively involved in the programme.

The bereavement midwife had developed strong external relationships with other organisations and local charities. This included the local registry office, a palliative care charity, funeral directors, perinatal pathology and coroner liaisons to improve the bereaved women and families' experience and outcomes. The trust reported 100% facilitation of religious and cultural wishes, including identifying and addressing a gap in Hindu chaplaincy and burial support. They had also provided bereavement baby hand and foot casting for a keepsake for bereaved families, which was funded by a charity.

The trust improvement and transformation lead midwife held regular focus groups for ethnic minority women to collect feedback about the service to improve service provision and women’s outcomes. The specialist midwife had also engaged with the MNVP and local mother and baby group to help inform women and their families about these focus groups. Feedback was shared with staff and senior leaders to drive improvement.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering staff training and quality of life for people.

Staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them.

Leaders encouraged innovation and participation in research. Staff had opportunities to participate in research. They had a research team who worked closely with the interim smoking midwife, public health team and maternal medicine to drive service improvement.

The trust maternity services were actively involved in the legacies and futures research study, which aimed to gain a better understanding of resilience and vulnerability in pregnancy.

The trust practice development team were also dedicated to finding new and innovative ways to provide training and information. This included the creation of human factors and medicine management training videos and plans for a maternity safety month initiative in January 2026.

The trust maternity services had been reaccredited to the UNICEF baby friendly initiative (BFI) gold award. This demonstrated the highest level of achievement around quality standards, leadership and breastfeeding and infant feeding support.

The birth centre worked with an external organisation to share their success and model of care. They were leading with the number of normal births and safe deliveries for mums and babies. The service consistently achieved between 15% to 25% of all in-patient births, compared to the 5% England average and LMNS average of 10%. The unit achieved around 25% births in September and November 2025. The unit had the highest number of deliveries in Southwest London and had options of hydrotherapy for women in each birthing rooms. The unit held weekly personalised birth planning clinics and regular out of guidance planning meetings for women and had a multidisciplinary team approach in planning and decision making. This helped staff to manage risk and promote informed choice for women. Women who chose to give birth out of guidance in the units were supported by staff and the consultant midwives. The out of guidance births in the unit was 28% (337 births) from January to November 2025. Staff were passionate and proud of their model of care which focused on strong working relationships, collaboration, early recognition of deviation, timely action, and a shared commitment to delivering safe, high-quality, compassionate intrapartum care.