Care Quality Commission

• Maternity services at Nottingham University Hospitals NHS Trust (NUH) are no longer rated inadequate after the Care Quality Commission (CQC) found improvements have been made. The overall rating of the service at both Nottingham City Hospital and Queen’s Medical Centre (QMC) has increased to requires improvement. The safety rating for maternity at the QMC and Nottingham City Hospital sites has also improved to requires improvement from inadequate.  

• The CQC also recognised significant improvements in the Trust’s leadership and culture, and how it is managed, increasing the well-led rating from inadequate to requires improvement. They found a reduction in staff reporting bullying with ‘significant progress in improving the culture’ and an executive team that ‘consistently led with integrity and were open and honest in their approach.’ 

• In maternity, significant improvements were found in the triage unit and day assessment unit, with 96% of all pregnant women seen within 15 minutes of arrival. Staffing concerns previously identified have improved with enough midwifery and nursing staff to keep women and babies safe. All women the CQC spoke to provided ‘overwhelmingly positive’ feedback on their care and treatment. Women are listened to and involved in their care.  

• As a result of the improvements seen by the CQC, the overall rating for Nottingham City Hospital has increased to good and there are now no services rated as inadequate. The overall rating for Queen’s Medical Centre remains requires improvement. 

The independent regulator of healthcare in England has said that, culture, leadership and maternity services are improving at Nottingham University Hospitals NHS Trust (NUH). 

The Care Quality Commission (CQC) inspected maternity services at the Queen’s Medical Centre and Nottingham City Hospital on 25 and 26 April, and carried out a well-led inspection on 6 and 7 June 2023.  

Publishing their findings today, the CQC increased the overall rating for maternity services at both sites from inadequate to requires improvement for the first time since 2020. For both sites, ratings improved in three of the five domains, including how safe the service is. Caring remains good at both sites.  

The report also highlights improvements in leadership and culture at the Trust following the well-led inspection. The overall rating for well-led has now increased from inadequate to requires improvement with the CQC finding ‘significant progress in improving the culture’ and an executive team that ‘consistently led with integrity and were open and honest in their approach’. 

Chief Executive Anthony May, who joined NUH in September 2022 welcomed the findings of the report. He said: “We are pleased that the CQC has recognised the improvements that colleagues at NUH have worked hard to deliver, both in terms of our maternity services, and in the leadership and culture of the organisation. 

“I want to thank our teams who work tirelessly to make our hospitals a better place and take pride in delivering the best possible care for patients. 

“Most importantly I hope the report provides confidence to local mothers and families who choose to give birth under our care, and that anyone who has had a poor experience can see the positive changes we are making, as well as listening to feedback and embedding improvements.   

“I am clear though that further improvements are vital, and in some areas, we need to do more to rebuild trust within our community. We are committed to fostering a culture where our colleagues can continue to improve services and deliver the care we all aspire to.”  

During their inspection, the CQC found a number of improvements in areas where concerns had previously been raised.  

• Previously, women had not been listened to regarding their care in maternity. At this inspection, the CQC observed staff who were skilled in communicating with women and their families. They found that all the interactions between staff, women and their families were caring, positive and informative. Women were listened to and involved in their care. During their inspection, the CQC noted that women gave ‘overwhelmingly positive’ feedback about the service and results from the latest national maternity survey showed that women giving birth in 2022 had a better experience that when giving birth in 2021. Feedback from women and families in the Friends and Family Test (June 2023) shows that 96% of respondents rate their experience as good or very good.  

• Significant improvements were seen in the triage unit and day assessment unit. This is described by the CQC as a ‘key achievement’ since the last inspection with 96% of all pregnant women being seen within 15 minutes of arrival in the triage unit. Staff especially demonstrated kindness towards the women attending and worked to make sure women did not stay longer than they needed to. Cardiotocography (CTG) monitoring for women, which was previously an area of concern, was now completed appropriately and was documented in line with national guidance. Staff said they felt confident in reviewing the traces and escalating when required.  

• Staffing concerns had improved with the CQC noting that maternity services provided enough staff with the right qualifications, skills, training and experience to keep women safe from avoidable harm and to provide the right care and treatment. They also found that managers regularly reviewed and adjusted staffing levels and skill mix. The CQC noted the focus on recruiting and retaining midwives, including the introduction of retention lead to oversee recruitment and retention. This included plans to improve staffing levels through a number of schemes, including international recruitment, return to practice, advanced clinical practice, and an increase in student midwifery university placements. 

• At the last well-led inspection, the CQC had concerns around the values and behaviours of some of the leadership of the Trust. During this inspection, the CQC noted that the executive team consistently led with integrity and were open and honest in their approach. Some staff still didn’t always feel able to raise concerns without fear of retribution, but leaders at the Trust were aware of this and were working to create a workplace that is free from bullying, harassment, racism, and discrimination. The CQC witnessed examples of where appropriate learning and action had been taken because of concerns raised. CQC inspectors found that most staff felt positive and proud to work in the organisation. 

Greg Rielly, CQC Deputy Director of Operations in the Midlands, said: “When we inspected Nottingham University Hospitals NHS Trust, it was positive to see improvements had been made across both maternity services and the trust’s leadership. It was clear that staff in all areas have been working hard to ensure changes are made so people can receive a better standard of care. 

“At both maternity services, we saw an improvement in the level of care being provided to people and their babies since we last rated both services as inadequate. It is positive to see that the trust is now on an improvement journey to bring about better and safer care. 

“Staff in both maternity services were kind and understood the personal, cultural, religious, and social needs of each person and showed understanding and a non-judgmental attitude when caring for or discussing people with mental health needs. 

“At our last well-led inspection, we had concerns around the values and behaviours of some members of the executive team and the negative impact this had on the wider trust. During this inspection, we saw a team that consistently led with integrity who were open and honest in their approach. 

“The executive team’s actions matched their words and owned up to their mistakes rather than blaming their team or making excuses. However, while the culture across the trust was improving and encouraged openness and honesty at all levels within the organisation, some staff still didn’t always feel able to raise concerns without fear of retribution. 

“Leaders were aware of this and were working to create a workplace that is free from bullying, harassment, racism, and discrimination so we hope to see an improved picture soon. 

“Within maternity services, staff must ensure thorough risk assessments are undertaken to ensure people and their babies are free from harm and abuse. Improvements are also needed to ensure medicines are stored and administered safely. 

“We will continue to monitor the trust, including through future inspections, to ensure the necessary improvements are made so people and can receive safe and appropriate care.” 

The report also identifies areas for further improvement in maternity services, including the management of medicines, infection prevention and control and ensuring thorough risk assessments are consistently undertaken. These, and other improvements are part of the Trust’s Maternity Improvement Programme, with progress reported publicly to the Board. During their previous inspection, the CQC was not assured the Trust was discharging its duty of candour responsibilities appropriately. The CQC found progress had been made, however there is more to do and further work is in progress. 

Anthony added: “Since our previous CQC inspections, we have put a significant focus on addressing the areas that we needed to improve, so it is pleasing that inspectors have noted the progress that we have made in a number of areas, including improved safety and staffing in maternity. They have also recognised the steps we have made in culture, including addressing bullying and harassment, and in encouraging colleagues to speak out in confidence.  

“We are grateful for the inspectors bringing areas where we need to improve further to our attention in the report, and we have plan to address each of these actions in the coming months.”  

Commenting on the improvements made in maternity services, Sharon Wallis, Director of Midwifery at NUH said: “It is clear that we are operating in challenging times for maternity services at NUH, but we are moving in the right direction and today’s CQC report is further evidence that we are improving.   

“We know we have more to do. We want the best possible outcomes for pregnant women and mums in our care, and for staff to feel supported to do their jobs to the best of their ability. We will continue to focus our efforts on delivering that outcome for them.” 

Amanda Sullivan, Chief Executive at NHS Nottingham and Nottinghamshire, said: “I am pleased to see this report, which shows improvements to both maternity services and leadership at Nottingham University Hospitals NHS Trust. I want to pay tribute to the hard work of the staff and the leadership team in bringing about this positive change. 

“We know there is still much more to do, but the CQC have reflected that the Trust is on an improvement journey. We will continue to work with the Trust’s leaders and staff to support them on providing an improved standard of care and developing a culture of openness and honesty.”   

Councillor Sue Saddington, Chairman of Nottinghamshire County Council’s Health Scrutiny Committee, said:  “As Chairman of the Health Scrutiny Committee at Nottinghamshire County Council I am pleased to hear that the Care Quality Commission have found some improvement within the maternity services at Nottingham University Hospitals NHS Trust.  

"The Trust Chairman and Chief Executive are extremely professional and I receive briefings from them on a regular basis.  I believe their leadership is exemplary.

“It is clear that they recognise there is more work to do but the steady, and I hope sustainable, improvement they have made so far is welcome.”

The full report will be published on CQC’s website on Wednesday 13 September.