City 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

Staff and leaders recognised that morale was low throughout the service with some staff reporting previous incidents of bullying. There was an independent review into culture underway. Some staff reported that not all members of the senior leadership team were visible or approachable. We found effective governance processes were not always in place and opportunities for learning were not always recognised or embedded. We found some policies were out of date and the trust did not always ensure practice was in line with national guidance or their own policy. Saving babies lives consistently did not meet targets and trust guidelines did not always align with national guidance. However, there was a 3-year delivery plan in place as well as a set of values and strategic objectives. The service had participated in external reviews. Leaders had arranged celebration events which included networking and a cake competition. Many staff were complimentary about their immediate line managers. There was a thank you Thursday initiative as well as a star of the month. Leaders recognised the challenges by a recent period of instability in the senior leadership team and that in the past leaders had not always been visible or understood the importance of staff engagement. Freedom to Speak processes were in place and monitored themes and trends. There was a health and wellbeing page for staff and an equality, diversity and inclusion midwife in post in addition to a risk and governance lead midwife.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff and leaders commented that staff morale was low throughout the service. Leaders told us that an independent review into culture was underway with agreed terms of reference. Several staff spoke of a ‘toxic’ culture, and the labour ward was named a number of times as being ‘cliquey’ by staff. Some staff became visibly upset when speaking about previous experiences of bullying and harassment, mainly by seniors.

There was a 3-year delivery plan in place. We reviewed the update from May 2024 and found it contained various objectives for each year which included areas such as achieving UNICEF baby friendly initiative accreditation and adoption of a National MEWS tool, National NEWTT-2 Tool. The plan was colour coded red, amber and green and showed 64 activities were coded as green and 19 as amber. We reviewed the trust annual plan dated 2023/2024 and found the trust set out its priorities, annual objectives, key projects and long-term development. The trust had a set of values in place alongside a vision and purpose. They also had strategic objectives which they named the 3P’s these being patients, people and population. We reviewed some slides on values and behaviours which set out the new trust values of ambition, respect and compassion. The slides also set out the expected behaviours relating to each value. The service participated in external reviews. For example, a Healthwatch report dated March 2023 sought to understand Black African and Black Caribbean women’s views of antenatal care, labour and birth in addition to post-natal care in West Birmingham. Findings from the research showed that Black African and Black Caribbean women had poor experiences of maternity care in West Birmingham. The key issues identified included racism and discrimination in maternity care, continuity of care, communication and information gap, being ignored, dismissed ad disbelieved, lack of dignity and respect and poor postnatal support. The report had identified improvements the participants would like to see. Leaders had arranged a nurse and midwives celebration event schedule, this included networking, awards and a cake competition.

Many staff we were complimentary about their immediate line managers. One midwife told us that ward managers were very accessible, others told us that their ward manager was “fantastic”. and their line manager very supportive. Staff spoke about the “Thank You Thursday” initiative as well as “Star of the Month”, where managers recognised the contributions, staff had made. However, some staff reported that not all members of the senior leadership team were visible or approachable. One staff member stated that senior leadership were “detached from reality”, another said that team “have no idea what my job entails.” Some staff recognised there had been recent changes to the senior leadership and expressed that they were hopeful that staff would be listened to, and changes made where necessary. Some staff raised concerns about the skills and experience of some of the Matrons who were part of the on-call escalation procedure. One staff member stated that some of the Matrons are non-clinical and “if they come in on escalation, they don’t know what to do.” Leaders recognised the challenges brought about by a recent period of instability in the senior leadership team. One senior leader reflected that previously leaders had not always been visible and understood the importance of staff engagement. Leaders said that the current quad were starting to work together well, and that a training package was being put in place to support them. The interim Head of Midwifery had a clear vision for what they wanted to achieve in post, including improving culture and staff morale, embedding of recommendations from each baby counts, and working more closely with their students’ host universities.

The senior leadership team quad consisted of an interim head of midwifery, group medical director, director of operations and group director of nursing for children’s services. There was also a part-time director of midwifery in post. The interim head of midwifery had only been in this role for 2-3 weeks at the time the assessment started but had previously worked as one of two deputy heads of midwifery. The second deputy head of midwifery was on maternity leave at the time of the assessment. Leaders told us that there had also been a general manager in the past, but they had not been able to re-recruit to this post. Staff had been given the opportunity to participate in a maternity survey Q4 23/24 which included various questions. The survey found 32% of staff felt they had a voice that counted, 24% felt they were recognised and rewarded, 60% felt they were a team and that they were compassionate and inclusive. There was a labour ward coordinator peer development plan in place with the aim of providing a framework for labour ward coordinators to access peer support and reflection and to enhance their capability in their role. Activities identified included action learning sets, coaching and mentoring. There was a matron’s developmental framework and competencies framework. These included areas such as inclusive leadership, professional standards and accountability, governance, patient safety and quality. There were compassionate and inclusive leadership modules that had been completed by 25 people in the women and child health directorate. Others had partially completed the required elements for the module. A leadership Compassionate and Inclusive Leadership Program was one of the key priorities that supported the trusts strategic people objective to cultivate and sustain happy, productive and engaged staff.

We interviewed the Freedom to Speak Up (FTSU) lead as part of the assessment. 7 concerns had been raised in Maternity since they started in post just over a year ago. They told us how they had 24 ambassadors throughout the organisation and 1 in Maternity. They had recently returned to working with Maternity services with group approval and found there were the same ongoing concerns around culture, staffing, acuity and staff feeling they could not raise their concerns.

There was a Freedom to Speak Up (FTSU) policy in place, this was in date and version controlled. The policy contained information for staff on areas such as what they could speak up about, who they could speak with and speaking up externally. There was an overall FTSU lead in place as well as 1 ambassador in the maternity core service. There were processes in place to record speaking up concerns including any themes, details, feedback and if a satisfactory resolution had been received. Themes of concern in 2023/2024 included culture, leadership/management, patient safety, behaviours relationships, attitudes and incivility.

Staff said that due to the ethnic diversity of the workforce, discrimination was not a problem, and staff who spoke about experiencing or witnessing bullying generally did not feel that it was targeted. However, 1 white British staff member felt that when she was bullied by a peer, this was racially motivated. Another member of staff who was black said of the Freedom to Speak Up team that there was “no-one who looks like me” (in the team). Staff were not aware of any staff equality networks. We reviewed details of a staff career workshop which took place in March 2022. The workshop was developed by the equality and diversity lead midwife following a discussion about the trust Workforce Racial Equality Survey data and other reports which indicated that not all staff members felt they had equal access to learning and development information that may enable them to develop in their careers. Stalls included representation from the trust apprenticeship team, clinical education and learning and development teams, a local university and the Royal College of Midwives. On the day the EDI lead midwife encouraged attendance, however some midwives expressed they wanted to attend but were unable to due to acuity on the unit. As a result of the event, an annual week-long event leading up to annual personal development reviews was recommended. We spoke with students in a focus group who said that they generally felt included when on clinical placement, and this was particularly the case on the antenatal and postnatal wards where students said staff enjoyed having them on the ward and thanked them for their help.

There was a health and wellbeing internet page with a page dedicated to occupational health and wellbeing. The page contained details of services such as details on the wellbeing hub, gym access and apps to help with flexible pay. There were links to a variety of leaflets such as physiotherapy services and on medical conditions and self-care. There was an equality, diversity and inclusion midwife in post. The service had recently began trialling the use of a service to allow non-English speaking patients to connect to a main helpline number with the help of a professional interpreter and involves the use of many languages. There was an equality and inclusion pocket guide devised by the equality and inclusion midwife. The guide included information on supporting asylum seekers, refugees and new migrants, obtaining out of hours interpreters, supporting the visually and hearing-impaired person, the LGBTQ+ person as well as those with a physical or learning disability. We saw actions were in place to improve equity for mothers, babies and race equality for staff, there was also plans to conduct a baseline assessment of the experiences of maternity and neonatal staff by ethnicity using WRES indicators. There were guidelines in place Caring for Expectant and Birthing Women or People with Learning disability and/or autism. The aim of the guideline was to offer practitioners within maternity services a good practice reference points to consider when working with people with learning disabilities or autism. There was an Equality Diversity and Inclusion Plan dated 2022-2027. The plan was set into four key quadrants including enabling collective leadership, creating a positive culture of compassion and inclusion, improving staff experience and delivering inclusive services to our patients and communities.

There was a risk and governance lead midwife in post. They told us the governance in maternity was well established., a local directorate group was brought in to add in challenge around areas such as training, ward assurances etc. A group of maternity safety champions met monthly, with members of the senior leadership team in attendance, to go through quality committee papers. They were aware of the top risks on the risk register. Senior leaders spoke about capacity issues in sonography but stated that there was a regional plan awaiting sign off. They spoke about some of the improvement initiatives. They said that there was an avoiding term admissions into Neonatal Units (ATAIN) working group in place. At the time of the assessment, they were planning to relaunch the warm bundle checklist as they noticed that temperature management was an issue. They also recognised an increase in hypoglycaemia and were launching a project on antenatal colostrum expression and education. They told us how they had also commissioned an audit into third- and fourth-degree tears, and this rate climbed above the national average. There was a foetal monitoring midwife who had been in post for a few months who was working on improving compliance with fresh eyes. Fresh eyes champions were recruited on the labour ward to raise awareness and also to be a ‘buddy’ if needed. We were told the foetal monitoring midwife did regular walkarounds to emphasise the importance of fresh eyes. The risk and governance lead midwife recognised the challenges that the new method of incident management would bring and that it was not an “overnight switch” for staff. Leaders told us a new maternity metrics dashboard was in development as the former dashboard was not helpful.

Effective governance processes were not always in place. Opportunities for learning were not always recognised or embedded, incidents had not always been escalated through designated pathways, audits did not consistently meet targets, trust guidelines did not always align with national guidance. Some policies were out of date and initial assessments of women and birthing people were not always in line with good practice or policy. Compliance targets for training were not always met. Our review of the perinatal review tools (PMRT’s) found they were not completed to the required standard. We found some risks had not been identified and acted on and that effective audit systems were not always in place to recognise that improvements were required. There was a departmental risk register in place however, we noted that many reviews were noted to be overdue. We found a large number of scheduled data entries onto the birthrate plus system had been missed. This meant the trust could not be assured of the planned and actual staffing within the maternity unit and the risks posed to women, birthing people and their babies. However, there was a governance and meeting structure in place. Groups had been set up to gather patient experience. There were processes in place to ascertain themes and trends and we saw thematic reviews had been initiated as a result. We also saw the service had taken actions in relation to external reviews and identified areas for improvement. A recruitment drive had recently been undertaken as well as a review into culture. The service had carried out various quality improvement projects, routinely collected and monitored information on people’s care, participated in peer reviews and benchmarked itself against other hospitals, they also used key performance indicators to measure performance in specific areas.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.