Queen's Medical Centre

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 care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last inspection we rated this key question as requires improvement. At this assessment, the rating remained requires improvement. This meant there were shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to the governance 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.

Leaders had a vision and strategy although this was in it’s infancy. The culture was improving but there were challenges with transparency and equity. However, staff understood the challenges and the needs of people and their communities.

There was a trust-wide strategy called “People First.” The priorities for this strategic framework were:

• Quality patient care
• Patient flow
• Retentions and recruitment
• Culture and leadership
• Financial Sustainability

Maternity services within Nottingham University Hospitals NHS Trust were included and referenced throughout this document.

The maternity leadership team had vision for the service; however, this was still in its infancy and had not been shared with staff. The leadership were struggling with capacity to fully consult and implement a maternity specific vision and strategy as much of their time was taken up with demonstrating assurance. This resulted from the service being the subject of an independent maternity review (IMR) and the ongoing investigations by the local constabulary into previous failings in care.

There was a non-executive director designated as the trust board safety champion, who reported they regularly visited the maternity unit and spoke to both staff and women. However, not all staff were able to recognise who the trust board safety champion was nor had any recollection of meeting them.

The service had an organisational development lead to support development (including future leaders), provide objective oversight of the service, and improve culture. However, staff reported some actions had been undertaken without consultation and context which caused them additional anxiety.

The service action plan in response to the Maternity Incentive Scheme and Saving Babies Lives care bundle met the requirements of the safety actions and declared compliance.

Leaders did not always demonstrate the ability to lead effectively. They were faced with pressures to deal with the challenges from extensive external scrutiny of the service, and this gave them insufficient time to run the department and be as visible and supportive as possible. However, they understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation.

Staff told us they felt supported by their colleagues about concerns or personal issues. However, several staff continued to describe frustrations of a lack of visibility of the maternity leadership and cultural challenges between midwives. Maternity services was part of the family healthcare group within the trust. The service was led by a leadership team of a clinical director for the family and healthcare group, a director of operations for the family and healthcare group, and the director of midwifery. There were also 2 heads of midwifery and a network of matrons to support staff across each site.

Staff reported they did not see the leadership team and would expect them to be more visible due to the increased scrutiny the service was faced with. However, some described feeling abandoned at times. When trying to find matrons to speak with as part of our on-site inspection, staff including senior midwives were unable to tell us where they were based or if they were even in the hospital. In addition, the midwifery leadership were not visible to those midwives working in the community or the homebirth team.

The director of midwifery presented to the trust board at every meeting about the progress the service was making in its improvement plan. We heard positive feedback of the support they received from the chief executive officer.

We heard staff did not raise concerns as they were not assured action would be taken by either the maternity leadership or the trust. Staff reported they were open and transparent if trust board members came to visit the unit despite directives to only share positive news.

Senior leaders spent most of their time fielding challenge and providing assurance as part of the independent maternity review. There was significant external scrutiny of the service from the trust board, NHS England, the local constabulary, and the parents affected by the historical failings in care. This resulted in the maternity leadership being unable to function as they should by being visible and supporting the team delivering the direct patient care.

Despite the service fostering a positive culture where people felt they could speak up, staff did not always feel they could speak up and their voice would be heard.

The trust had a freedom to speak up policy and processes to allow the freedom to speak up guardian (FTSUG) to support staff to raise concerns.

The guardian’s team produced a quarterly newsletter that was included in the trust briefing which was cascaded out to divisions and was included in divisional people committee papers however, staff were unable to articulate this process. Which meant the process may not have been effective.

The guardian attended new staff inductions and several regular meetings. For example, they attended all divisional people committees, maternity engagement calls, and the neonatal improvement work stream to raise awareness of the process.

However, some staff we spoke with were not aware of who or how to contact the guardian. Therefore, the service was not assured the processes to support staff to speak up were effective.

As part of this inspection, we encouraged staff to share their experiences anonymously online with us. We received several contacts from staff raising concerns. We used these to direct parts of our inspection and any potential actions. We repeatedly heard staff did not always escalate concerns to the maternity senior leadership team as they were not confident their concerns would be heard or acted upon.

However, staff were confident in speaking with the professional midwifery advocate team. There was support for newly qualified midwives and there was a programme of support for the band 7 midwives implemented. However, there was a gap in the support offered to band 6 midwives who were providing most of the preceptorship to the band 5 newly qualified midwives and internationally educated midwives. Some staff described being exhausted and drained. We escalated our concerns regarding the band 6 workforce to the executive leadership to urgently manage this problem and increase support.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service did not always have effective oversight of day-to-day operations, many of these had been identified in previous inspections and had not been rectified. However, the service had clear responsibilities, roles, systems of accountability. Staff used these to manage and deliver good quality, sustainable care, treatment, and support. Staff acted on the best information about risk, performance, and outcomes, and shared this securely with others when appropriate.

All breaches in regulation identified in this inspection had been reported on since October 2020 and enforcement action taken to drive improvement. For example, medicines management, breastmilk storage, staffing, baby abduction, visibility and effectiveness of the senior leadership team. During this inspection these breaches continued and demonstrated governance processes within the service were not always effective.

Staff explained how information was sent mostly by email, which they did not have the capacity to access leading them to feel disconnected at times. Additionally, staff were not involved in discussions around changes to procedures which meant they did not always understand the process leading to confusion. This was evident in the storage of breastmilk and the variety of processes we observed during the inspection.

The cultural concerns which staff shared with the inspection team had not been identified through the services own governance processes. Staff reported leaders did not hear them and act upon their concerns therefore staff stopped reporting cultural concerns. For example, when they experienced incivility from women and their families.

There was a clearly defined governance structure outlining oversight and accountability from the service level to the trust board. Governance leads implemented governance processes and monitored key safety and performance metrics through a structured programme of governance meetings. Nonetheless, considering the repeated breaches and concerns identified during the inspection, assurance regarding the overall effectiveness of these arrangements could not be confirmed.

Staff at all levels could describe their role in the governance process and had regular opportunities to meet, discuss and learn from the performance of the service. They knew how to escalate issues to the clinical governance team. There was a head of midwifery specifically for oversight of quality risk and safety, who was supported by a consultant obstetrician who had protected time for this role. However, there were vacancies in the governance team which meant there might be delays in investigations. However, this was not evident during this assessment.

Governance meetings were held weekly and fed into the perinatal oversight meetings. The weekly governance meeting agendas included discussion around all aspects of governance and oversight of data. Data discussed included performance data, audits and training, feedback, guidelines and research. As part of the assessment, we reviewed audit data including maternity early obstetric warning score (MEOWS), and cardiotocograph fresh eyes, and found they were completed and discussed by the maternity team.

The maternity risk register was managed by a lead risk midwife, who was able to use risk articulation tools to calculate scores. Risks which scored above 16 were escalated to the trust risk management group who provided check and challenge. We saw the top risks for the maternity service matched those articulated by the maternity leadership.

We reviewed trust board minutes which showed maternity items were regularly part of the agenda. Items included serious incidents, performance reports, performance data and the maternity incentive scheme.

The service clearly understood and carried out its duty to collaborate and work in partnership, and services worked seamlessly for people. Staff always shared information and learning with partners and collaborate for improvement.

The service had an active Maternity and Neonatal Voices Partnership (MNVP) which contributed to decisions about care in maternity services. The MNVP had built a genuinely meaningful relationship with the maternity service. The MNVP was led by a chairperson and had 14 people working with them to improve services for women.

The MNVP were passionate about their role and had regular contact with leaders to make a difference to services provided to women. The MNVP also conducted regular walkarounds of the maternity unit to speak to staff, women, and their families about their experiences and how things could be improved.

The MNVP engaged with charities and organisations to address inequalities and improve the experience and outcomes of women and families.

The service worked with the local university and offered placements to students with a view to encouraging them to join the trust after graduation. The service had a 100% retention rate for the students who trained there. We spoke to students during our inspection who confirmed they were well supported in each of their placements and hoped to be offered a role when they qualified.

The organisation worked with Maternity and Newborn Safety Investigations (MNSI) following patient safety incidents such as maternal and baby deaths, responding to investigation action plan requirements.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome, and quality of life for people. Staff actively contributed to safe, effective practice and research.

Staff were encouraged to put forward change suggestions. However, the mixed feedback identified methods of staff engagement were not always effective.

Leaders we spoke with had a clear focus on the challenges and improvements being made across the service. They identified the trust’s vision and strategy for the current service which identified commitment to continuous improvement and learning through several projects, driven by the Maternity Improvement Programme.

Current processes to review outcomes and develop learning and improvement included, for example, maternity governance reporting to the board to drive learning and improvement, a data driven maternity dashboard, and a perinatal improvement and oversight group.

Incident themes were also reviewed and debriefed. This learning was shared within the 10 at 10am to share learning and actions. However, we did not see that these were consistent across all areas within the service.

The 2024 NHS Maternity Survey for Nottingham University Hospitals NHS Trust showed there were no areas where the trust scored below the average. Additionally, we saw maternity services at Nottingham performed better than the national average in three areas: women were more often offered a choice of where to give birth (9.7 vs. 8.2), partners or companions were more involved during labour and birth (9.8 vs. 9.4), and support for infant feeding during evenings, nights, or weekends was more accessible (7.2 vs. 6.0).

We saw from the 2023 survey to that of 2024, there was a significant improvement in the scores. The most notable improvement was in postnatal care, where more partners were able to stay with mothers during their hospital stay (score increased from 8.7 to 9.4). All other scores remained stable, with no areas showing a decline.

The service held a shared learning workshop to reflect on the survey findings. Key areas were identified for improvement in 2024/25 include enhancing communication, strengthening support for infant feeding and respecting individual choices. Also enabling women to ask questions about their labour and birth experience. An action plan was developed in partnership with the Maternity and Neonatal Voices Partnership and was in the process of being implemented. Progress was monitored through the established governance groups and shared with the Local Maternity and Neonatal System.