The Hillingdon Hospitals NHS Foundation Trust

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
• Environmental sustainability – sustainable development

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The trust had a clear vision and a set of values, with quality and sustainability as the top priorities. At the time of the assessment, the trust was developing a shared vision and strategy with other partners. This meant that there was some uncertainty about future strategic objectives.

The trust is part of the North West London Acute Provider Collaborative (APC) which brings together the four acute providers within North West London. The trust was the smallest of the trusts within the APC and there were discussions about the trust sustainability as a sovereign entity. This meant that there was the prospect of significant change at leadership level which would impact on future direction.

The trust’s corporate strategy, ‘Looking ahead; our plans for the next five years 2022-2026’, was published in October 2022. The strategy was aligned with local health and social care plans.

Our interviews with senior leaders demonstrated that the trust strategy was reliant on the delivery of a new hospital as part of the government funded ‘New Hospitals Programme’ (NHP). There was no alternative strategy or plan in place should the government funding not be approved. Whilst senior leaders felt confident that the new hospital build would go ahead – this represented a significant risk to the organisation. Despite this being raised at board level by non-executive directors, there was no alternative strategic plan.

After our inspection and following the government’s recent review of the New Hospital Programme, on 10 January 2025 the Secretary of State for Health and Social Care published his report and announced that the new Hillingdon Hospital will proceed as a wave 1 scheme, with construction expected to start 2027/28 and a capital envelope of £1-£1.5bn.

The trust identified areas for development related to the NHP, which included working with partners to strengthen and help lead the hospital transformation programmes and in developing the operating model and design for the new Hillingdon Hospital.

The trust described their values and behaviours as central to their strategy for the future, guiding every aspect of their work so they could offer the best patient experience for people who use their services. The trust values are ‘Communication, Attitude, Responsibility, Equity and Safety (CARES).

CARES week took place in Autumn 2023 and focused on a ‘big listen’ and seeking feedback from colleagues on the values. While CARES values were embedded within the organisation, the trust told us the behavioural framework underpinning the CARES Values was not fully embedded and needed to be relaunched. This had not been arranged and implemented at the time of our assessment.

The strategy sets out everything the trust aims to achieve for their staff, local community and partners in six aligned strategic objectives:

• Quality - We will deliver consistent high quality, safe and compassionate care
• People - We will be a great place to work and an exemplar employer.
• Performance - We will deliver the right care at the right time for our patients
• Finance We will maximise resources available for the benefit of patient care
• Partnership - We will be an active system partner leading strategic change
• Strategic Programmes - We will progress delivery of our strategic programmes

The trust had developed an annual plan detailing the key deliverables to deliver the six objectives. Management oversight was by the trust executive board, chaired by the chief executive. Assurance was through the associated Hillingdon Hospitals sub committees and APC sub committees and the board in common, where delivery is reviewed in comparison to the other three hospital trusts in the North West London APC.

The trust has developed enabling strategies (all approved between 2020 and 2022) to support the delivery of the overall strategy:

• Clinical Services Strategy
• Estates Strategy
• Digital Strategy
• Transformation Strategy

The Trust’s 2024/25 quality priorities had been identified through engagement with multiple stakeholder groups; they were:

• Implementation of the first phase of Calls for Concern in response to Martha's Rule, (Martha's Rule is a major patient safety initiative providing patients and families with a way to seek an urgent review if their or their loved one's condition deteriorates and they are concerned this is not being responded to).
• Effective embedding of the recently introduced (Patient Safety Incident Response Framework) PSIRF programme and share learning from the process
• Reducing health inequalities in the maternity service at the Trust
• Improve clinical outcomes in relation to falls by maximising effective use of data provided by digital sources such as monthly integrated quality performance report (IQPR) and electronic patient records system reports.
• Reduce the harm caused to patients when undertaking invasive procedures by implementing Local Safety Standards for Invasive Procedures (LocSSIPs) and National Safety Standards for Invasive Procedures (NatSSIPs).

The achievement of each quality priority was monitored and reported through established committees and groups, that in turn reported through the Quality and Safety Committee, a sub-committee of the board in common.

The trust attends and participates in the Integrated Care Board (ICB) System Quality Group where there is a system approach to safety and learning.

We met with members of the Patient Engagement Forum during the inspection who told us they were invited to give their opinions on the trust strategy. The trust’s Chair of Governors described positive communication achieved by an ‘open door’ to the Vice-chair of the board in common.

Promotion of Health and Wellbeing (HWB) offers persisted throughout the year, including activities such as directing individuals to mental health resources, providing menopause support, addressing financial wellbeing, and conducting targeted HWB visits to identified areas. The trust held monthly CARES Awards and annual staff awards.

We heard staff of all grades describe the culture in the trust as a ‘Hillingdon family.’

Between September and November 2023, 1,721 staff took part in the NHS Staff survey, which was an improved trust response rate of 48.2% from the previous year’s 40% (compared to a national average response rate of 49.7%). The detailed results of the survey showed that the trust position had improved across all seven of the People Promise elements, and the two themes of engagement and morale. Overall, the trust’s score on the People Promise elements in the NHS staff survey were slightly below the average, except for ‘we are a team,’ which was slightly above average.

In 2023, 50.5% staff responded positively that they would recommend the trust to a friend or relative, which was a slight improvement on the previous 2 years trust results, but worse than the national average of 63.3%.

In the last 12 months, the trust was within the expected range or flagged as better than other trusts for sickness rates for total staff.

Since our inspection the trust has appointed a new CEO in common with Chelsea and Westminster NHS Foundation Trust.

Our interviews with leaders at all levels demonstrated that leaders did not always have the capacity to ensure strategic delivery despite their commitment. Senior leaders told us that the continued collaboration in the APC would lead to greater capacity through shared governance and working practices. However, this was yet to be fully explored and implemented.

Since our last well led assessment in 2018, the trust had become a member of the North West London Acute Provider Collaborative (APC), a formal partnership established with the 3 other acute NHS Trusts in the geographical area of north west London. Each trust remained an independent organisation with a Chair in common and a Board in common.

The trust board comprised the Chair-in-common. Vice Chair, eight Non-Executive Directors and one Associate Non-Executive Director. The board in common had seven committees, each chaired by a non-executive director.

The board in common comprised individuals with senior level experience in the public and private sectors, across a range of disciplines including clinical and patient care, health service leadership, commercial development, business transformation and change management, finance, governance, risk management, and human resources.

There was a relatively new executive leadership team at the trust with 50% of the membership appointed in 2023/24, so were still learning how to work together as a team. There was no formal board development programme in place.

There was not a system in place to develop future leaders. Leaders we spoke with told us the trust’s talent management and succession planning approach needed to be implemented. The trust acknowledged that their internal leadership development training offer had limited capacity and more could be done to support senior leaders and the Board in their continuous professional development (CPD), promoting consistent leadership standards and behaviours to ensure their vision was delivered and risks managed.

Leaders told us they undertook regular visits to frontline services. These visits improved leadership visibility and ensured leaders were able to triangulate the information received through the trust’s governance systems, particularly in relation to staff experience. The Senior Leads Walkabout Programme was recommenced in March 2023. The aim of this programme was to increase senior leaders’ visibility in clinical areas. A total of 123 visits had been undertaken from April 2023 to March 2024. The themes from the walkabouts were captured on a regular basis and updates were given at the Hillingdon Care Quality Programme meetings. The programme structure was being reviewed to expand it to Non-Executive Directors. However, whilst the programme increased visibility, some staff said they felt that there was a missed opportunity to actively listen, respond and act on challenges raised.

The breakdown of the trust’s workforce is 59.1% BME, 38.8% White and 2.2% Unknown/Not Disclosed (Workforce Race Equality Standard 2023/24). There was no representation of people from ethnic minority groups on the executive, who were all white. Leaders told us the trust valued and recruited diversity at senior levels, however, we did not see tangible evidence of how they were actively working to improve this.

Partners told us they felt that the trust board had the experience, capability, and personal values to lead the trust. Most partners were positive about individual leaders and shared examples of positive partnership working.

As an NHS Foundation Trust, the trust has a Council of Governors and 5482 public members. The Council of Governors represented the interests of the local communities, patients, public and staff, and shared information about key decisions with Foundation Trust members.

The trust had a Fit and Proper person policy, and we found records to be in line with the requirements.

The trust had a Level 3 team leader apprenticeship which they were delivering in partnership with Harrow, Richmond Uxbridge Colleges.

‘Management Fundamentals,’ a series of masterclasses, were available to staff covering topics such as how to have Personal Development Review (PDR), time management, communication, listening skills, and difficult conversations. Additional masterclasses had been introduced during 2023/24 including managing conflict and expanded career development support such as mock interviews.

People did not always feel they could speak up and that their voice would be heard.

Leaders were not always viewed as acting with openness, honesty, and transparency. Staff said leaders did not always address concerns leading to some staff finding it difficult to speak up. We received feedback that described “toxic cultures,” highlighting “numerous incidents” and “distressing experiences personally endured” by staff. These included abusive behaviour and racism directed at Black and Asian staff. Staff had referred their concerns to external bodies and persons. Leaders had investigated concerns and engaged staff to improve the problems and records confirmed this. However, they needed to do more to ensure staff felt safe to report concerns.

Strategies to promote staff empowerment and improvement were not yet fully embedded. Some staff remained unsatisfied with the measures which they said did not address the root cause of the issues. Staff from minority ethnic groups reported poorer workplace experiences.

The organisational culture did not always encourage staff to proactively raise concerns despite the systems, policies and procedures in place. The Freedom to Speak Up Guardian (FTSUG), FTSU champions and management teams provided staff space to raise concerns. However, some staff told us they feared reprisals or not being believed so reported concerns anonymously. CQC received information of concern anonymously, in which staff expressed fear of retribution. The trust responded to concerns raised by undertaking investigations, having conversations with staff and reviewing practices. In our survey of partners in stakeholder engagement events, most partners did believe the trust met the description of the Freedom to Speak Up quality statement.

The FTSUG worked on a part time basis which limited their impact. The trust was in the process of considering additional support that may be required. The numbers of staff raising concerns via FTSU was generally better than other similar sized NHS trusts. The trust ensured staff were aware of the FTSUG and had access to related policies to enhance their understanding and confidence in reporting concerns. The FTSUG had access to a senior executive team lead and a non-executive board member to ensure investigations were conducted with rigor and to help escalate issues, where needed.

Initiatives to improve the model of speaking up required more engagement with staff to be effective. The FTSUG was supported by a team of 19 FTSU Champions and work was required to raise awareness of their role in the workplace. They had ongoing work to ensure staff were aware of the various channels through which they could report concerns. The trust had an initiative to make the FTSUG more accessible through implementing a digital solution across the organisation. The FTSUG worked closely with the senior leadership team. The trust completed the Self-reflection Tool as mandated by NHS England for all Trusts, which then contributed to an improvement plan. The trust had a FTSU strategy to support best practice and information from the FTSUG was discussed at the Workforce Executive Committee, Trust Executive Board and People Committee.

There were efforts to promote the Equity Diversity and Inclusion and health and well-being roles to increase their effectiveness. The FTSUG also took part in staff induction, walkabouts, and attended team huddles, helping staff to reconnect with the Trust’s values. They undertook an FTSUG staff survey podcast on confidentiality and the importance of employee voice. They developed an FTSU training package. They worked closely with the National Guardian’s Office (NGO) to develop their role and promote speaking up culture across NHS organisations. Despite this work, not all staff felt confident to speak up which meant the trust needed to do more.

The Non - Executive Director with responsibility of the FTSUG reported to the board where they presented an annual report highlighting an overview of the themes emerging from staff speaking up to the FTSUG. The Board were made aware of lessons learnt and changes to practices to encourage improvement.

There were not always effective governance and assurance systems in place to support the delivery of good quality sustainable care and treatment. All levels of governance and management did not always function effectively and interact appropriately with each other. This was highlighted through our most recent assessments of maternity (inspected in July 2023), surgery and emergency department (ED) (inspected in July 2024). We found significant concerns in these areas that should have been identified through the trust own governance and assurance processes. Since the assessment, the trust has submitted a comprehensive action plan to address significant concerns raised in relation to processes, people, and estates.

The trust governance processes and systems were being developed in line with strategic objectives. The trust had recently entered into shared governance arrangements with 4 other acute and specialist trusts in September 2022. The 4 trusts had a board in common with a single chairperson that met quarterly. The Hillingdon Hospitals NHS Foundation Trust held a quarterly standing committee meeting which was attended by the trust board and chaired by an experienced NED. This model of shared governance was in its infancy and yet to be fully embedded at Hillingdon Hospitals.

The trust had appropriate committees, sub-committees, and meeting structures to ensure that sufficient information could be escalated to the Trust board. Staff at all levels were clear about their roles and what they were accountable for. There was a board assurance framework aligned to strategic objectives and the corporate risk register. However, our review of documents and interviews with executive leaders demonstrated that actions were not always taken to minimise risk and improve safety in line with strategic objectives.

We were not assured that the trust always took timely and effective action to address gaps in assurance processes to ensure patient safety and quality care. For example, the trust’s external audit for 23/24 highlighted weaknesses in assurance systems in relation to monitoring compliance to regulatory standards. At the time of the trust level assessment there were no action plans in place to address these fundamental concerns. Addressing these concerns would allow the trust to have greater oversight to minimise the risk of avoidable harm. The Board Assurance Framework contained historic risks with limited information about mitigations or review. There were assurance systems to ensure that performance issues were escalated through clear structures. This included a systematic programme of clinical and internal audit to monitor quality, operational and financial processes, and systems to identify where action should be taken. Any gaps in assurance processes were identified through the trust’s internal and external audit systems.

There were arrangements in place to identify and manage risks. This included systems to record mitigating actions and issues. However, leaders did not always take appropriate or timely actions to address identified risk and minimise avoidable harm. For example, during our assessments of urgent and emergency care and surgery we found that significant improvements were required in medicines optimisation to keep people safe. The risks related to medicines optimisation had already been identified as a corporate risk by the pharmacy team. We were not assured that the board had sufficient oversight of the organisational risks related to medicines optimisation. The risks recorded were highlighted during our assessments of urgent and emergency and surgical services. In response to the S29A warning notice the trust took immediate actions to strengthen processes and governance in medicines optimisation which we will continue to monitor through the trust’s action plan.

There were systems in place to ensure that the quality of care was not impacted by financial challenges. The trust had cost improvement plans (CIP) in place and had set itself the strategic objective of maximising the resources available for the benefit of patient care. The trust had a history of financial challenges and had recently exited the highest level of financial scrutiny in December 2023. The trust’s senior leaders worked hard to ensure that meeting their statutory financial requirements did not impact on patient safety and quality care. However, we were concerned that the pressures related to financial challenges meant that the trust did not always take action when needed. For example, the trust had significant issues with their estates and at the time of the assessment they were waiting for a final decision as to whether or not they would receive funding under the government’s new hospitals programme. Our interviews with staff at all levels demonstrated that changes that were needed to estates were being incorporated into the new hospital programme. Whilst this was an attempt to manage finances appropriately, this had an impact on patient experience and was a risk to people’s safety. After our assessment of the emergency department, the trust took immediate actions to address estates issues which had already been identified as areas of concern. Since the assessment the trust has received approval and funding to progress with the new hospital build.

In terms of financial governance, at the time of the trust level assessment, there had been significant change in the financial leadership of the Trust. The chief financial officer had left the Trust in September 2023; the chair of the Trust finance committee retired at the end of September 2023; and the chair of the audit and risk committee had joined in May 2024. The Trust had decided to appoint an interim director chief financial officer with significant experience. In 2024-25, the Trust expects to receive income of c£357million and had submitted break-even plans to relevant bodies. At the time of the inspection, the Trust had reported a year to date deficit of £17.1million at the end of August 2024; a variance of £14.8million from its agreed plan. The Trust expected to spend c£42mn on improvements to its estates, equipment and digital capacity in 2024-25. The focus of the Trust’s capital plans remains the rebuilding of the Hillingdon Hospital.

There were processes in place to manage current and future performance. This included an integrated quality performance report (IQPR) and regular performance meetings. Performance meetings covered all relevant topics. Our interviews with senior leaders demonstrated that the trust was well sighted on performance related to national targets such as referral to treatment times and accident and emergency performance indicators. For example, at the time of the assessment, the trust was on target to have zero patients waiting longer than 52 weeks for referral to treatment (RTT) by December 2024. This had been a challenge for the trust since December 2022 with increasing demand since the pandemic. The trust had made improvements in some cancer performance metrics, the trust had met the faster diagnosis standard (FDS – people with certain cancers have a diagnosis within 28 days) from February to July 2024. The trust remained challenged in areas such as ED 4 hour performance (national target 75% of type 1 ED attendances to be discharged, treated or admitted within 4 hours) which was 42% in July 2024 against a trajectory of 55%. Senior leaders confirmed that the trust was improving its processes to develop a more holistic approach to managing performance which incorporated and triangulated information from feedback from patients and staff. This was being developed through continuous improvement methodology which was becoming embedded across the organisation.

The trust had systems in place to ensure that accurate and reliable information was available to inform decision making and improving performance. The trust had implemented an electronic patient record system in November 2023. This was in line with national requirements to allow organisations to share information related to patient care and enable better joined up care. The trust was exploring more ways to harness this technology to improve care, maximise harm reduction and provide better information for teams. Our review of documentation and interviews with staff at all levels demonstrated that whilst the information available was generally sufficient, there were areas to improve with the flow of information. For example, concerns in relation to medicines optimisation could be more prominent at board level to support the organisation with decision making around this crucial area of care.

The trust regularly reviewed its governance and risk systems. The most recent internal review (July 2024) highlighted areas of good practice and areas for development. The trust had business continuity plans in place to deal with unexpected emergencies that affect service delivery and processes in place to ensure that people’s information was managed in line with legal data protection regulations. This is reflected in the trust’s annual data security and protection toolkit report.

There were appropriate structures and systems in place to ensure that people’s human rights were considered, and people were safeguarded against abuse in line with legislation. The trust had relevant named leads for specific areas including mental health, dementia and learning disabilities. Our interviews with the safeguarding leads demonstrated that the team worked hard to ensure that safeguarding and people’s liberty was key to service delivery. Where challenges were identified such as compliance with statutory and mandatory training, the team worked with teams and individuals to ensure that targets are met. This is reflected in the trust’s annual safeguarding report.

The trust had processes in place to prevent and control infections. The board received an annual infection, prevention and control report and regular updates via the IQPR at board meetings. The trust worked with external stakeholders and partners in care to review and develop governance and performance management systems and processes.

There were not always effective governance and assurance systems in place to support the delivery of good quality sustainable care and treatment. All levels of governance and management did not always function effectively and interact appropriately with each other. This was highlighted through our most recent assessments of maternity (inspected in July 2023), surgery and emergency department (ED) (inspected in July 2024). We found significant concerns in these areas that should have been identified through the trust own governance and assurance processes. Since the assessment, the trust has submitted a comprehensive action plan to address significant concerns raised in relation to processes, people, and estates.

The trust governance processes and systems were being developed in line with strategic objectives. The trust had recently entered into shared governance arrangements with 4 other acute and specialist trusts in September 2022. The 4 trusts had a board in common with a single chairperson that met quarterly. The Hillingdon Hospitals NHS Foundation Trust held a quarterly standing committee meeting which was attended by the trust board and chaired by an experienced NED. This model of shared governance was in its infancy and yet to be fully embedded at Hillingdon Hospitals.

The trust had appropriate committees, sub-committees, and meeting structures to ensure that sufficient information could be escalated to the Trust board. Staff at all levels were clear about their roles and what they were accountable for. There was a board assurance framework aligned to strategic objectives and the corporate risk register. However, our review of documents and interviews with executive leaders demonstrated that actions were not always taken to minimise risk and improve safety in line with strategic objectives.

We were not assured that the trust always took timely and effective action to address gaps in assurance processes to ensure patient safety and quality care. For example, the trust’s external audit for 23/24 highlighted weaknesses in assurance systems in relation to monitoring compliance to regulatory standards. At the time of the trust level assessment there were no action plans in place to address these fundamental concerns. Addressing these concerns would allow the trust to have greater oversight to minimise the risk of avoidable harm. The Board Assurance Framework contained historic risks with limited information about mitigations or review. There were assurance systems to ensure that performance issues were escalated through clear structures. This included a systematic programme of clinical and internal audit to monitor quality, operational and financial processes, and systems to identify where action should be taken. Any gaps in assurance processes were identified through the trust’s internal and external audit systems.

There were arrangements in place to identify and manage risks. This included systems to record mitigating actions and issues. However, leaders did not always take appropriate or timely actions to address identified risk and minimise avoidable harm. For example, during our assessments of urgent and emergency care and surgery we found that significant improvements were required in medicines optimisation to keep people safe. The risks related to medicines optimisation had already been identified as a corporate risk by the pharmacy team. We were not assured that the board had sufficient oversight of the organisational risks related to medicines optimisation. The risks recorded were highlighted during our assessments of urgent and emergency and surgical services. In response to the S29A warning notice the trust took immediate actions to strengthen processes and governance in medicines optimisation which we will continue to monitor through the trust’s action plan.

There were systems in place to ensure that the quality of care was not impacted by financial challenges. The trust had cost improvement plans (CIP) in place and had set itself the strategic objective of maximising the resources available for the benefit of patient care. The trust had a history of financial challenges and had recently exited the highest level of financial scrutiny in December 2023. The trust’s senior leaders worked hard to ensure that meeting their statutory financial requirements did not impact on patient safety and quality care. However, we were concerned that the pressures related to financial challenges meant that the trust did not always take action when needed. For example, the trust had significant issues with their estates and at the time of the assessment they were waiting for a final decision as to whether or not they would receive funding under the government’s new hospitals programme. Our interviews with staff at all levels demonstrated that changes that were needed to estates were being incorporated into the new hospital programme. Whilst this was an attempt to manage finances appropriately, this had an impact on patient experience and was a risk to people’s safety. After our assessment of the emergency department, the trust took immediate actions to address estates issues which had already been identified as areas of concern. Since the assessment the trust has received approval and funding to progress with the new hospital build.

In terms of financial governance, at the time of the trust level assessment, there had been significant change in the financial leadership of the Trust. The chief financial officer had left the Trust in September 2023; the chair of the Trust finance committee retired at the end of September 2023; and the chair of the audit and risk committee had joined in May 2024. The Trust had decided to appoint an interim director chief financial officer with significant experience. In 2024-25, the Trust expects to receive income of c£357million and had submitted break-even plans to relevant bodies. At the time of the inspection, the Trust had reported a year to date deficit of £17.1million at the end of August 2024; a variance of £14.8million from its agreed plan. The Trust expected to spend c£42mn on improvements to its estates, equipment and digital capacity in 2024-25. The focus of the Trust’s capital plans remains the rebuilding of the Hillingdon Hospital.

There were processes in place to manage current and future performance. This included an integrated quality performance report (IQPR) and regular performance meetings. Performance meetings covered all relevant topics. Our interviews with senior leaders demonstrated that the trust was well sighted on performance related to national targets such as referral to treatment times and accident and emergency performance indicators. For example, at the time of the assessment, the trust was on target to have zero patients waiting longer than 52 weeks for referral to treatment (RTT) by December 2024. This had been a challenge for the trust since December 2022 with increasing demand since the pandemic. The trust had made improvements in some cancer performance metrics, the trust had met the faster diagnosis standard (FDS – people with certain cancers have a diagnosis within 28 days) from February to July 2024. The trust remained challenged in areas such as ED 4 hour performance (national target 75% of type 1 ED attendances to be discharged, treated or admitted within 4 hours) which was 42% in July 2024 against a trajectory of 55%. Senior leaders confirmed that the trust was improving its processes to develop a more holistic approach to managing performance which incorporated and triangulated information from feedback from patients and staff. This was being developed through continuous improvement methodology which was becoming embedded across the organisation.

The trust had systems in place to ensure that accurate and reliable information was available to inform decision making and improving performance. The trust had implemented an electronic patient record system in November 2023. This was in line with national requirements to allow organisations to share information related to patient care and enable better joined up care. The trust was exploring more ways to harness this technology to improve care, maximise harm reduction and provide better information for teams. Our review of documentation and interviews with staff at all levels demonstrated that whilst the information available was generally sufficient, there were areas to improve with the flow of information. For example, concerns in relation to medicines optimisation could be more prominent at board level to support the organisation with decision making around this crucial area of care.

The trust regularly reviewed its governance and risk systems. The most recent internal review (July 2024) highlighted areas of good practice and areas for development. The trust had business continuity plans in place to deal with unexpected emergencies that affect service delivery and processes in place to ensure that people’s information was managed in line with legal data protection regulations. This is reflected in the trust’s annual data security and protection toolkit report.

There were appropriate structures and systems in place to ensure that people’s human rights were considered, and people were safeguarded against abuse in line with legislation. The trust had relevant named leads for specific areas including mental health, dementia and learning disabilities. Our interviews with the safeguarding leads demonstrated that the team worked hard to ensure that safeguarding and people’s liberty was key to service delivery. Where challenges were identified such as compliance with statutory and mandatory training, the team worked with teams and individuals to ensure that targets are met. This is reflected in the trust’s annual safeguarding report.

The trust had processes in place to prevent and control infections. The board received an annual infection, prevention and control report and regular updates via the IQPR at board meetings. The trust worked with external stakeholders and partners in care to review and develop governance and performance management systems and processes.

The trust recognised their duty to collaborate and work in partnership with others in the system to refine and develop patient pathways.

Our interviews with senior leaders, observations and review of documentation demonstrated that the trust was committed to developing positive and collaborative relationships with external partners. This included within the Northwest London acute provider collaborative. Senior leaders acknowledged that whilst this is a positive arrangement and opportunity to learn from each other and share resources; there was still some work to do to fully realise the value of the collaborative.

The trust was a part of a local place-based partnership. The focus of the partnership is to build and strengthen working relationships between health, local authority, other stakeholders and service providers who can work together and improve outcomes for local communities. The partnership had implemented a community-based bed operating model that had helped reduce the length of stay at Hillingdon hospital for ‘patients not meeting the criteria to reside’.

The trust had positive relationships with community and patient groups. For example, there was a positive relationship with the maternity and neonatal voices partnership and council of governors.

The trust had formed a partnership with a local higher education institute to support education, employability, innovation and research and networking.

We found that several issues identified in previous inspections remained unresolved. Despite the presence of governance structures and processes for monitoring risks and performance, some key challenges, such as those related to capacity, access, and flow, persisted. The service leadership was aware of these ongoing issues, but actions to address them had not been implemented in a timely manner, and plans for improvements were still in development without imminent changes.

Additionally, while the service had mechanisms in place for learning from incidents and reviewing patient safety alerts, the effectiveness of these measures in bringing about prompt improvements was limited, as some previously highlighted risks remained current. Several incidents remained open, with some overdue for investigation. This suggested that while the service had systems in place for learning from incidents, the effectiveness of these measures was hindered by delays in the resolution and closure of these cases. These open incidents reflected a gap between identifying issues and implementing effective solutions to mitigate risks and improve patient safety promptly.

Senior leaders and staff were committed to continuous learning, improvement and innovation. The trust had embarked on a journey of continuous improvement utilising recognised quality improvement methodology in 2022. Senior leaders described the cultural change that was required to embed a culture of learning through quality improvement (QI). There had been some challenges with embedding QI throughout the organisation. At the time of our assessment this was yet to be embedded, however, the trust was making significant improvements in this area and had identified actions to strengthen QI capability and capacity.

The trust identified improvement priorities based on organisational priorities and feedback about the needs of patients. For example, the trust had utilised QI methodology to support the improvement work in maternity services.

Senior leaders continued to support the embedding of continuous improvement by ensuring that leaders at all levels completed QI training. Staff had access to standardised QI tools and guidance to tailor their improvements to their needs with the support of dedicated staff.

Senior leaders welcomed the opportunity to receive feedback from external reviews. We saw evidence that senior leaders made improvements from recommendations from external bodies. For example, the trust had made significant improvements with the learning environment for junior doctors and had been removed from General Medical Council enhanced monitoring in July 2024.

The trust had a director of professional research and development. The trust actively participated in clinical research which was usually led by medical staff. Senior leaders were actively engaging with nursing and allied health professionals to undertake principal investigator roles (lead on research projects); however, this was challenging for all staff who had or were developing research skills due to time constraints and operational pressures.

The trust had been early adopters of the patient safety incident response framework (PSIRF) in 2023. This framework was introduced by NHS England to replace the previous incident response framework with a focus on patient, carer and family involvement and emphasis on learning.

The trust had a green plan in place that reflected NHSE guidance and the national Greener NHS Guidance. There were effective processes to track progress against targets and respond to relevant data collections such as the Greener NHS guidance and the Estates Returns Information Collection (ERIC). The green plan identified how the trust would manage the environmental impact of implementing the strategic objectives set by the trust board. The trust’s Director of Estates and Facilities was the board-level sustainability lead for the trust’s green plan. The plan articulated focus areas and objectives for travel, buildings, waste, virtual appointments, medicines, food, culture, and ways of working.

Partners were aware that the trust had a green plan. The trust plans were aligned with wider system plans, particularly the local integrated care board Green Plan.

The trust has evidenced key successes in its environmental sustainability work, this included, reduced energy consumption across the Trust by 12% since 2021, 75% of the trust transport fleet is now electric or hybrid (with zero diesel vehicles), 9 out of 13 patient transport ambulances in the fleet are electric, with a fully electric fleet expected to be in place by March 2025, 70% water savings achieved since 2020, 100% renewable electricity including the commencement of generating electricity through solar power.

The trust has received 14 national and regional awards including the national HEFMA Efficiency and Innovation Award. The trust was able to evidence how they have effectively embedded a sustainability culture throughout the organisation, this included a mandatory sustainability awareness course for all staff, waste management training for key staff, and the establishment of several public engagement forums to drive awareness and seek local solutions.

The trust worked creatively to focus their sustainability efforts via its estate strategy despite the constraints of the aged hospital estate. Further work was needed to ensure that medicines sustainability was embedded into clinical decisions and pathways.