HTG-UK East – Norwich

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• 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.

This is the first assessment for this newly registered service. This key question has been rated inadequate.

This meant the service management and leadership was inconsistent. Leaders and the culture they created did not support the delivery of 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 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.

The service was in breach of regulation for safe care and treatment and governance at 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.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

Our assessment, informed by consultation with staff, leaders, and partners, highlighted gaps in developing and communicating a clear, shared vision and strategy for the service. While one manager acknowledged that improvements could have been made during the induction phase of the newly acquired service, demonstrating some openness to learning, this attitude was not consistently reflected across the wider leadership team.

Staff consistently reported poor communication from leaders, describing challenging interactions between operational teams, commissioners, and senior management. Leaders, however, were dismissive of concerns, attributing issues to a small number of individuals, despite our experience of widespread staff dissatisfaction.

Although leaders considered holding listening events, only one had taken place, and staff felt that bulletins and noticeboard updates were insufficient to enable meaningful engagement.

This disconnect contributed to a culture of dissatisfaction, with staff expressing low morale, diminished motivation, and concerns about their wellbeing. Many felt unsupported in delivering the high-quality care they aspired to provide, indicating that the organisational culture did not align with staff values or the needs of the service.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

At the time of our initial site visit, the senior leadership team were based off-site, which limited direct oversight and visibility. Following this, leaders relocated to be based on-site, enabling improved governance, visibility, and assurance. This change enabled more immediate engagement with staff and strengthened leadership presence in day-to-day operations.

Leaders were at times dismissive of widespread staff concerns, attributing issues to a small number of individuals, despite clear evidence of systemic dissatisfaction and operational challenges. This reflected a disconnect from the realities of frontline service delivery.

Staff reported poor communication, inadequate support, and a culture of blame. Leaders did not create a culture of openness or psychological safety, and staff did not feel empowered or valued in their roles.

We reviewed 5 staff complaints relating to managerial conduct. Our review found that the responses provided did not consistently demonstrate a supportive approach or reflect a fair and impartial investigation. In several cases, the tone appeared defensive and focused on attributing blame rather than addressing concerns constructively.

Managers acknowledged operating closed-door policies, further undermining openness and accountability.

Staff morale was low, motivation was affected, and many felt unsupported in delivering high-quality care. The lack of meaningful engagement, limited listening events, and ineffective communication channels contributed to a culture of dissatisfaction.

Overall, the evidence portrays leadership as disconnected, defensive, and lacking in transparency, with insufficient attention to staff wellbeing, service context, and organisational values. This highlighted the need for significant improvement in leadership behaviours.

We scored the service as 1. The evidence showed significant shortfalls. People did not feel they could speak up and that their voice would be heard.

Staff had access to a Freedom to Speak Up Guardian. However, the role was held by the Human Resource lead, which raised concerns about impartiality and undermining trust in the process. Although this was a new initiative, it was not viewed as appropriate or independent. As a result, some staff bypassed internal routes, raising concerns directly with NHS hospital guardians or commissioners, while others escalated issues through their unions. This lack of confidence in internal mechanisms reflected a culture of limited psychological safety and risked delaying the resolution of serious concerns affecting staff wellbeing and patient care.

We scored the service as 2. 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.

Leaders did not always promote an inclusive and fair culture for its workforce. Staff did not always feel respected, valued or supported, and many reported that their views were not listened to or taken seriously when they raised concerns. Several described interactions with leaders where communication felt dismissive or unconstructive, and we saw examples of internal investigations that focused on assigning blame rather than promoting learning or improvement. These experiences contributed to staff feeling discouraged and uncertain about whether concerns would be acted upon.

Staff reported inconsistent access to the information and clinical support they needed to safely carry out their roles. For example, staff were not always provided with complete information about risks, which affected their ability to plan care and respond effectively. Limitations in staffing levels and skill mix further contributed to variations in the support staff received.

There was little evidence of structured engagement or collaborative problem‑solving with frontline teams, and many staff told us they did not feel positive or proud about working for the provider. Some staff also reported that concerns about mental wellbeing were not always met with compassionate support, and in some cases responses felt punitive.

Staff feedback was not routinely gathered using surveys or other formal mechanisms to identify issues or drive improvements. As a result, the provider could not demonstrate that equality, equity or inclusion were being consistently promoted or monitored across the workforce.

Despite these concerns, there were examples of positive practice. Staff were able to request flexible working arrangements, and managers made reasonable adjustments for staff with physical health needs to help them carry out their roles.

The organisation had an up‑to‑date Equality and Diversity Policy that set out clear commitments to fairness, inclusion and preventing discrimination. Staff had access to support for their physical and emotional wellbeing, and leaders could access psychotherapeutic support where required. Staff achievements were also recognised through awards and positive feedback, and staff told us they remained committed to patient care and believed they could feel more motivated with better support and resources.

Overall, while the provider had policies and some supportive practices in place, these were not consistently implemented or experienced by staff. The service did not always demonstrate an inclusive or fair culture, and further work was required to improve equality and equity for those working within the organisation.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

A governance framework and policy were in place. However, the requirements outlined in the policy were not consistently reflected in practice. For example, while the policy referenced supervision and appraisal, we found no evidence that these activities had been carried out.

Risk management and strategic planning were ineffective, resulting in repeated operational failures such as aborted journeys and persistent lateness. This reactive approach highlighted weaknesses in governance and oversight.

Training compliance reporting was inaccurate. Although leaders claimed 93% compliance, internal data showed only 4% in October 2024, with key safety modules still below expected thresholds by August 2025. This raised concerns about data reliability and the effectiveness of governance.

Operational managers were not given access to the risk register, and leaders did not expect them to be familiar with it. Staff concerns were not included in the register, highlighting poor risk awareness and ineffective governance structures.

Infection control measures were inadequate, with visible hygiene risks including cracked flooring, overflowing bins, and unidentified fluids near mobility equipment. Staff handling bodily fluids lacked access to appropriate wash facilities, indicating poor oversight and creating risks for both staff and patients.

Safety checks for equipment and stock control systems were absent, and leaders did not demonstrate awareness of these risks, compromising the safety within the care environment.

The risk register lacked sufficient detail, omitting key operational risks such as workforce challenges, cultural issues, and training gaps. This suggested governance systems were not being used effectively to monitor and manage threats to service quality.

Recurring performance risks, such as delays in renal transport, were not addressed despite consistent incident themes, indicating a lack of learning and improvement following the service transition.

Audits and incident reporting processes were in place but were not used effectively. Staff concerns and dynamic risk assessments were frequently disregarded, resulting in repeated failures and missed performance targets.

Frontline staff engagement was limited, with little evidence of collaborative problem-solving. Staff felt unsupported and blamed when raising issues, which directly impacted their ability to deliver safe, effective care.

Although new leadership had set out a vision for improvement, governance arrangements at the time of our inspection did not provide assurance of safe care or adequate staff support. Operational failures persisted due to the absence of meaningful planning and risk mitigation.

We scored the service as 2. The evidence showed some shortfalls. The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Leaders worked collaboratively with commissioners and referring hospitals, holding regular meetings focused on improving service delivery. These interactions demonstrated a willingness to work in partnership and acknowledge external feedback. Commissioners offered support to strengthen outcomes and communication, indicating a shared commitment to improvement.

Partners raised concerns about quality of this service.

Referring hospitals raised concerns about risks to patient care and failures to meet key performance indicators. These challenges suggested that while structures for partnership working were in place, they were not used effectively to drive meaningful improvement or restore confidence in the service.

We scored the service as 2. The evidence showed some shortfalls. The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Leaders did not have fully embedded systems to support learning, improvement or the consistent identification and management of risks. Good practice was not reliably translated into day‑to‑day operations. Staff were not always equipped with the practical guidance or support they needed to apply safer, more effective approaches in real‑time. This limited the impact of otherwise promising initiatives and highlighted gaps in how leaders monitored, implemented and reinforced learning across the service.

Although leaders had begun work to promote safer, more person‑centred care, these efforts were still at an early stage and were not yet fully integrated into routine practice. Systems to support continuous improvement and the application of learning remained underdeveloped. Leaders had not consistently demonstrated the sustained commitment or follow‑through required to ensure that learning resulted in meaningful, practical change.

Despite these shortfalls, leaders had expressed an intention to align practice with least‑restrictive principles in line with national guidance and current research. This showed a thoughtful and progressive attitude toward care delivery. However, the benefits of this approach were not yet realised in daily practice due to the lack of robust implementation and monitoring mechanisms.