North East London 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 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Trust leaders had ensured there were shared values and a strategy in place. The trust had recently completed the launch of its updated values and strategy 2025-2030. These had been co-produced with people who used services, staff and stakeholders. This co-production had taken place through a number of place-based events, staff events and surveys. Staff, people who used services, governors and external stakeholders confirmed their participation in this work.

The trust’s values were: we are kind; we are respectful and we work together with our communities. Whilst relatively new, staff were aware of the trust values and understood how they applied to their roles.

The strategy had three overarching goals and was based on the NHS triple aims. These goals were to improve the health and wellbeing of our communities; improve the quality of our services and use resources wisely.

At the time of the inspection the directorates were producing their annual plans. This bottom-up approach enabled each directorate to decide how the strategy would be adopted and translated into operational plans. The planning at place meant that the trust was able to recognise inequalities in their local communities and work to address these. These plans considered financial constraints and local commissioning arrangements. The directorates were setting their priorities with outcome measures, so they would be able to measure their success. This enabled the trust to monitor and review their progress against the trust strategy and identify any risks. This work was at an early stage but people we spoke to during the inspection were aware of and engaged with this process.

The trust had an adult mental health clinical strategy which was launched in May 2024. This recognised the need for a specific focus on these services. At the time of the inspection the trust had launched its relational care faculty which was a key enabler of the adult mental health clinical strategy. The trust had been shortlisted as one of the NHS England Trieste-programme sites looking at new models of care at place giving the trust associate site status in Waltham Forest. This was in recognition of their focus on relational care and the use of Open Dialogue – an approach which emphasises direct communication and collaboration between the individual, the professionals with families and social networks.

A medicines optimisation strategy was in place. Regular updates on the medicines optimisation plan were provided to the executive and board on a quarterly basis.

Pharmacy key performance indicators (KPI’s) which aligned to the trust strategy were in place for each service area. KPI outcomes were available to all pharmacy staff through a dashboard. The pharmacy strategy had been developed collaboratively with all staff. Every 12 months there was a team away day. This gave everyone the opportunity to be involved and plan for the year ahead. Every 6-months there were check-ins to temperature check how staff were delivering the pharmacy plan.

Senior leaders referred to the trust values and strategy. The governance arrangements ensured that the priorities of the trust were monitored. For example, in the previous year, a partnerships and integrated care committee had been introduced as a new sub-committee of the board linked to the goal of improving the health and wellbeing of the communities supported by the trust. The integrated performance report which came to each board meeting, reviewed the performance in delivering the trusts strategic priorities.

Throughout the well led review we received largely positive feedback about the visibility of senior leaders and the culture of the organisation. We heard about how the board held its meetings at different sites, as the trust covered such a large geography, so the meetings were accessible to people who wished to attend. Board meetings always included a session hearing from people who use services and carers. There had also been a reset of board visits to services. These were now happening regularly, and we heard that board members were approachable and interested in the services they were visiting. Staff felt able to speak openly about challenges they were facing. Board members spoke about the benefits of visiting services and meeting people who used them and staff. Themes from the visits were written up and these were seen as key parts of the trusts quality management system.

Staff also told us about how they found directorate leaders largely accessible and open in their approach. Most staff said they felt able to raise concerns and ask for support. A few staff in very pressurised front-line services expressed frustration at the length of time it was taking to address things like staffing challenges. However, they recognised that senior leaders were aware of the challenges and improvements were being made.

Trust leaders were prioritising the development of a just and compassionate culture. This promoted equality, diversity and human rights. At the time of the inspection the just and compassionate leadership programme had trained four cohorts of staff with 176 graduates. A leading inclusively with cultural intelligence masterclass had been attended by 538 staff. Staff commented during the inspection on the value of this training and the difference it was making to the approach of trust leaders.

Trust governors reported that there were some ongoing challenges in their work with the board. The trust chair was a joint position with a neighbouring trust, East London Foundation Trust. There had been significant concern that the trusts would be merged which had made it hard to develop a positive trusting relationship. These difficulties were acknowledged, and work was ongoing to reach a shared understanding of the role of the governors and how they could perform their role most effectively. A recently appointed member of the corporate governance team was focusing on supporting the governors and this was felt to be helpful input.

Feedback from system partners commented on the how the current leadership was much stronger and more engaged in system work as a whole. They found that the trust was much more open and willing to share information with system partners. They were also able to recognise where services needed to improve.

The trust had processes to identify and address behaviours that were inconsistent with the values of the NHS. This had included the development of a trust resolution framework co-designed with staff side and implemented across the organisation. There was also a civility and respect handbook and training which had been rolled out across the trust. A monthly workforce assurance group, reporting to the people and culture sub-committee of the board, monitored complex disciplinaries via exception reporting and monitored suspensions (there were 6 at the time of the inspection), monitored grievances (22 at the time of the inspection) and ensured employee well-being checks were up to date. They also monitored resolution processes, formerly grievance and bullying and harassment (there were 7 at the time of the inspection). This monitoring did not indicate how long processes were taking to conclude. It reviewed trends so interventions could be considered if needed. The trust acknowledged that staff changes in the HR team which oversaw this work were challenging at the time of the assessment.

We observed the trust’s board meeting, attended several governance meetings and reviewed minutes. These included the sub-committees of the board. In all meetings we saw leaders acting with integrity, respect and demonstrating a passion for delivering services to meet the needs of the communities.

The trust’s board comprised of nine executive directors including the chief executive and nine non-executive directors including the trust’s chair. There were plans to increase the number of non-executive directors to ten people. Since the previous well led review the experience of health and social care across the board had been strengthened. Two new executive director posts had been created, an executive director of partnerships who had experience of health and social care; and an executive director of allied health professionals, psychological professions and social work. Three non-executive directors had brought their experience of working as a GP, nursing in the acute sector and working in the third sector.

The executive team had individual portfolios covering all the necessary areas of work for the trust. These included patient safety, quality of care, risk management, performance, finance and organisational development. Some of the executive directors had very large portfolio’s especially the nurse director, but they felt confident that they had the necessary support to enable them to have the capacity for these roles. Individually agreed arrangements including mentoring had been put into place to promote each executive director’s professional development.

The was a recognition that there had been a lot of changes in the board. The chair reflected that by the end of 2025, 15 of the 19 members of the board would have changed since she joined in January 2023. This meant that there had been an investment in board development using an external facilitator to support this work. Sessions had included working as a unitary board; strengthening systems of assurance and developing the trust strategy. There was a programme of joint board sessions with the neighbouring mental health and community health trust. In addition, there had been a joint board session with one of the acute trusts located in the North-East London system. Members of the board felt that they were working effectively under the stewardship of the chair and chief executive.

The chair and chief executive were both mindful of the succession planning for board members. At the time of the inspection a recruitment process was underway for new non-executive directors that included replacing people who were near the end of their term of office. All the executive directors managed senior leaders who were developing the skills and experience to potentially be future trust leaders. They also considered the diversity of the board and recognised the importance of recruiting more members from a global majority heritage. However, the chair also valued the experience brought by non-executive directors who had lived experience of using services and those who were carers.

At the time of the well led inspection the trust was facing a charge for corporate manslaughter and the court case was nearing its conclusion. Trust leaders were very aware of the impact on staff associated with the case. The deputy chief executive officer had been attending court throughout the case and was available to support staff. Other arrangements had been made to provide psychological support. Trust leaders had ensured that the work of the trust to improve adult mental health services was being continued.

The trust had a fit and proper person policy, and board members had completed checks in line with the requirements, including a thorough search of their social media.

The trust was organised into 8 directorates. Seven of these were aligned to geographical areas with a focus on the services delivered at place. In some of these localities there were just adult or children services and in others the services covered all ages. There was one directorate named acute and rehabilitation which focused on the London mental health services.

The trust was focusing on building the clinical and patient leadership within the integrated care directorates but there was more to do, particularly in relation to medical leadership. Medical leadership was an area for improvement identified at the previous well led review. The plan was for each directorate to have leadership which included or represented nursing, medical, psychological professions, allied health professions, patient involvement leads and pharmacy. Medical consultants who carried out the role of associate medical directors told us that mostly they were not given the time to carry out these roles alongside their clinical responsibilities and that as a result decisions were still largely manager led. There were examples of where this was progressing better, such as the new medical leadership posts in the acute and rehabilitation directorate. At the time of the inspection a plan was being developed to restructure medical leadership and to launch a medical leadership development programme, but this had not yet been implemented.

It was positive to hear of some of the benefits from the strengthened clinical leadership from pharmacists, psychological professions, allied health professionals and social workers. Examples included the creation of four community psychology leadership posts who were supporting psychological professionals to use quality improvement to develop services to address health inequalities. For allied health professionals there had been about 50 apprenticeships introduced to the trust growing the future allied health professional establishment. The social work leadership was improving partnership working with local authorities to improve the out of hours approved mental health professionals to support the demand capacity and flow of acutely unwell mental health patients.

During the inspection we heard that corporate services were aligned to place so that corporate services were part of place-based teams. This included finance, HR, data and insight. Directorate leaders valued the support they received from corporate service colleagues.

The staff survey results indicated that whilst staff working across the trust were finding their day-to-day work experiences challenging the overall 2024 national staff survey results had been largely positive relative to other mental health and community health trusts. The response rate had been 56% compared to a national average of 52% and an improvement on the previous years score of 53%. The trust had an engagement rating of 7.22 compared to a national average of 7.11 and 7.66 for being compassionate and inclusive compared to a national average of 7.58.

The trust had a freedom to speak up strategy and policy. A freedom to speak up guardian (FTSUG) had been appointed at band 7. They had historically sat within the corporate affairs directorate but with the appointment of an executive director of allied health professionals, psychological professions and social work, the FTSUG had been realigned to fall within their portfolio. A non-executive director lead for freedom to speak up had also been identified. In addition to the FTSUG, 20 freedom to speak up champions had been identified across the trust to promote awareness.

All staff received information in relation to speaking up during induction. Those who were interested in becoming champions undertook specialist training. The FTSUG had attended team meetings and away days to promote awareness of the role. During our inspection of community and inpatient services we found there was good awareness of the FTSUG and their role.

The 2024 NHS Staff Survey showed that staff agreeing with the statement ‘I feel safe to speak up about anything that concerns me in this organisation’ had fallen slightly from 68% in 2023, to 66.17% in 2024. This was slightly below the national average of 66.58%. The survey also showed that in 2024, 57.58% agreed with the statement ‘If I spoke up about something that concerned me, I am confident my organisation would address my concern’. This was a decrease from 59.43% in 2023. The trust score was slightly above the national average in 2024 of 54.93%.

The FTSUG reported to the quality and safety committee and submitted regular reports to them and the board. The December 2024 report to committee found that over the previous 18 months, 301 freedom to speak up contacts had been made. Of these, the highest number of concerns involved bullying, harassing or inappropriate behaviours by staff to other staff. Concerns about the quality of care delivered by a service or to an individual patient fell to between 30% 50% in this same period. The trust was looking to expand the data sources available to the FTSUG so that their findings could be triangulated against other sources, for example HR data. This was still in development at the time of our assessment.

Throughout July 2024, the FTSUG ran sessions with various staff groups across the trust. Fifty-three colleagues attended in total and were asked about their views and experiences of speaking up in NELFT. Their reflections and comments highlighted barriers to raising concerns, as well as colleague experiences when they did speak up. Comments included heightened feelings of staff vulnerability in the context of the corporate manslaughter trial and Lampard enquiry; a shifting culture following significant changes at board level and uncertainty in a climate of significant cost cutting measures.

The FTSUG advised that concerns were predominantly raised by staff working in mental health services, in community and inpatient settings.

The trust had developed an impressive global majority staff network and anti-racist strategy. Work force race and work force disability equality standards, showed that there was more work to do. The trust had a well established equality and diversity team. They provided support and budgets to each of the staff networks. Each network reported to the people and culture committee regularly and to the board annually. Networks also had a clearly identified executive director sponsor.

The trust had most recently reported to the board regarding work force race and disability equality standards in August 2024. Data in those reports covered the period from the 1st of April 2023 to 30th March 2024. Where available, data has been updated to include the outcome of the 2024 NHS staff survey, which was published shortly after our assessment.

Overall, the percentage workforce from the global majority (people of black, mixed, Asian and other ethnic backgrounds) had increased. Nearly 47% of staff identified as global majority, compared to just over 50% of staff who identified as white. The gap between staff who identified as global majority and staff who identified as white had narrowed considerably since 2017.

Metrics used to evaluate work force race equality showed mixed results. Four metrics showed improvement. Two showed decline and 2 showed no significant improvement. Whilst global majority staff were still more likely to enter formal disciplinary proceedings than white staff, this metric had shown improvement. Global majority staff were now 1.4 times more to enter formal disciplinary, an improvement on the 1.6 likelihood of 2022. However, the percentage of global majority staff entering formal disciplinary remained high and global majority staff continued to be over represented at 57%.

Improvements were also seen in the relative likelihood of white staff accessing non-mandatory training. The percentage of global majority staff who accessed non-mandatory training and continuous professional development (CPD) was 49% in 2023. The figure for white staff was the same. In 2023, 81 members of the global majority network accessed the trusts bespoke LEAP programme, which aimed to support career development and retention of global majority staff in leadership roles.

The percentage of global majority staff experiencing harassment, bullying or

abuse from patients, relatives or the public in the last 12 months showed improvement from 2022 to 2023. However, NHS staff survey results published in 2024 showed this metric stalling slightly, with 22.99% of global majority staff experiencing this compared to 22.17% in 2023.

Global majority representation at board level had improved. In 2023, 33% of non-executive directors identified as being from the global majority. Two executive directors identified as being from the global majority.

There was more work to do in addressing the appointment of global majority staff at band 8 and above compared with the percentage of staff in the overall workforce. There had been no significant increase in the number of global majority staff at this level. The numbers of global majority staff at band 8 and above (36%) was 10% below the level global majority staff represented across the trust.

The relative likelihood of white applicants being appointed from shortlisting across all posts compared to global majority applicants also needed to improve. The relative likelihood of white staff being appointed when compared to staff from the global majority had increased to 2.01 in 2023. Whilst the overall percentage of global majority staff appointed had increased to 43% in 2023, the number of white staff appointed had risen to 53%. The remaining metrics used to measure workforce race equality had not shown any significant change.

Metrics used to evaluate work force disability equality showed more polarised findings. Five metrics showed improvement. Six showed decline and 3 showed no significant improvement.

The metrics showing improvement included the representation of staff identifying as disabled in medical, senior manager and executive level posts when compared to the percentage of staff identifying as disabled in the overall workforce. There had also been a significant of improvement from 2022 to 2023 in the relative likelihood of non-disabled applicants being appointed from shortlisting compared to disabled applicants. Improvements were also seen in the percentage of staff saying that they had felt pressure from their manager to come to work, despite not feeling well enough to perform their duties. However, 2024 NHS staff survey results showed that this improvement had not been maintained and number of disabled staff feeling pressured to work when unwell rose from 18.31% in 2023 to 21.5% in 2024.

Staff who identified as disabled said there had been improvements in their voice being heard. Advances had also been made in the representation of staff who identified as disabled as part of the trusts board voting membership.

Six metrics showed that staff who identified as disabled believed they experienced worse outcomes than non-disabled staff. These included the relative likelihood of entering the formal capability process and being twice as likely to experience harassment, bullying or abuse from managers or colleagues. Whilst the 2024 NHS staff survey showed the trust had made some progress in disabled staffs’ experience of bullying and harassment from colleagues, the upward trend in this experience from managers continued. This metric rose from 12.4% in 2023 to 14.2% in 2024.

There was a 10% gap between the number of disabled staff and non-disabled staff in their view of whether the trust provided equal opportunities for career progression and promotion. Whilst this metric showed a slight downward trend over the last couple of years, the 2024 NHS staff survey showed that it had stabilised somewhat; moving from 55.12% in 2023 to 55.91% in 2024.

The percentage of disabled staff who reported that reasonable adjustments

were made in the workplace declined in 2023; however, the 2024 NHS staff survey showed improvement as this rose from 74.8% to 76.07%. During our conversations with staff, we received positive feedback on their ability to access reasonable adjustments. The remaining metrics used to measure work force disability equality showed no significant change.

The equalities and diversity corporate team worked with staff networks to develop action plans in relation to the workforce race equality standard (WRES) and workforce disability equality standard (WDES). At the time of our inspection there were 11 networks operating within the trust. These were:

• Mental health network
• Disability staff network
• Armed forces staff network
• Global majority staff network
• LGBTQ+ staff network
• WoMens staff network
• Autism staff network
• Dyslexia specific learning disabilities network
• Hearing support network
• Parents carers staff network
• Religion belief network

From our observations and the feedback we obtained, we saw that some network groups convened more regularly, and had numbers of core and general attenders that were more reflective of the groups representation across the trust. The trust was considering whether a refresh and relaunch of some of its networks would be appropriate. The trusts global majority network’s LEAP programme won the ‘outstanding corporate achievement of the year’ award at the national black and minority ethnic health care awards in October 2024.

The trust was an earlier adopter of the patient and carer race equality framework (PCREF), launching in 2022. PCREF is a practical tool to help mental health trusts work with ethnic minority communities and understand what steps they can take to achieve practical improvements in terms of their access, experience of services and outcomes. The trust employed a small team to lead on PCREF. At the time of this assessment the trust had six workstreams in progress. These included addressing the over representation of black men in acute mental health settings; improving access to mental health services and talking therapies for south Asian women; building better, culturally sensitive support, for black and south Asian women during pregnancy and birth.

Since our last assessment the trust had signed the anti-racism pledge and launched its anti-racism strategy. This encouraged continuous learning and aimed to address inequalities based on race for both staff and service users. Staff we spoke to throughout the inspection, reflected on the positive impact of the anti-racism strategy in terms of encouraging staff to speak about racism and improving the culture of the trust.

There were seven sub committees of the unitary board. These were quality and safety, people and culture, finance and investment, audit and risk, partnership and integrated care, patient leadership and renumeration. The board met six times a year and the sub-committees fitted in with these meetings. Key risks and updates were shared in a report from each sub-committee to the board. The non-executive directors (NEDs) were aligned to the sub-committees and also attended meetings which they did not chair to get a broader understanding of the work of the trust. There was a clear description of the work of each sub-committee. Each subcommittee of the board had an annual programme of work to ensure all areas were reviewed.

The governance processes for the executive directors operated through ​four committees called strategic delivery groups each chaired by an executive director.​ These were care, people, value and partnerships. These reported into sub-committees of the board. Other executive members who did not chair a strategic delivery group (SDG) were responsible for portfolios that formed part of the work of the SDGs, for checking that the wider ramifications of SDG decisions were discussed with other executive colleagues and teams, and for inviting anyone else who needed to be present to allow for effective decision-making.​ Each directorate and pharmacy services was represented at each SDG to facilitate collective decision making and awareness.​

The governance arrangements in each directorate varied slightly for example, linked to the local systems, service configurations and leadership arrangements. However, each directorate through governance meetings were held to account on performance, quality of care, finances and culture. Whilst these variations made it challenging to understand all the local arrangements, directorate staff could describe them and understood how they worked in practice. The inspection of the acute mental health wards did highlight a few areas where improvements were needed, such as the care plans for physical healthcare conditions and the recording of restraints. Whilst the trust has systems for monitoring this work, including audits, other monitoring checks, use of performance data - this had highlighted the need to ensure that the means of assurance were sufficiently consistent and robust.

The current board assessment framework (BAF) had just been refreshed at the time of the well led inspection. The BAF aligned to strategic priorities and recorded 10 principal risks. Each one had an executive lead, identified the committee with oversight and the linked primary strategic priority. The BAF also highlighted links with high risks on the operational risk register. All recorded risks included the drivers of the risk and potential consequences with a risk rating. For each risk there were mitigations, agreed actions with dates and a progress update. Whilst this was new it was very thorough, providing a robust framework for the board.

Each directorate put current risks on the operational risk register. The risks were scored and the actions to address them were clearly recorded. Progress with addressing the risks were monitored through the governance processes. Risks which posed a significant risk to delivery of the trust’s strategic priorities, or risks that could not be mitigated at directorate level were escalated. The operational risk register informed the board assurance framework maintaining oversight of significant risks which, if they materialised, may affect the strategic direction of the trust.

At the time of the inspection, the main concern from system partners in North-East London was the demand versus capacity for the adult and child mental health services. This was impacting on the numbers of people spending lengthy periods of time in the acute trust emergency departments. This was leading to a poor and at times unsafe, experience for people with mental health needs. It was also affecting the space available for the emergency departments to meet the needs of other patients. When looking at the mental health emergency department (ED) wait times, focusing on 12-hour breaches as a percentage of total mental health ED attendances, for the first 3 quarters of 2024/25, this was an average of 37% for the trust. The London average for the same timescale was 30%. North-East London NHS Foundation Trust was an outlier compared to all the other London mental health trusts. The trust had made a number of interventions including, using live data to monitor mental health patients in the ED; opening a crisis house in Redbridge and plans for a crisis café; extending the capacity and effectiveness of the psychiatric liaison teams; increasing inpatient beds with plans to expand this further (recognising the historic under commissioning of beds); increasing the capacity of the integrated care and assessment hub (ICAH) – although the planned extended opening hours had not started at the time of the inspection. This was starting to have an impact with 12-hour breaches at 28% for the final quarter of 2024/25. Whilst the trust governance processes were closely monitoring the use of out of area inpatient beds, it was not doing the same for the 12-hour and 72-hour breaches, which meant that the impact of the work to improve access might not clearly be available to the board.

The trust had a guardian of safe working hours, they had last reported to the board in November 2024. Working practices for trainees at the trust were safe. From July 2024 through to the end of September 2024 there were two exception reports submitted by core trainees, both in psychiatry. No exception reports were submitted by specialist trainees or foundation year doctors. The trust had arrangements in place to complete medical appraisals and revalidation.

The Nursing and Midwifery Council and General Medical Council had both provided feedback about the trust and had not highlighted any concerns. The trust was referring individuals as needed as part of its fitness to practice procedures.

Appropriate systems to govern the management and administration of medicines were in place. The chief pharmacist had been in post for 2 years and reported directly to the chief medical officer. The chief pharmacist was also the trust controlled drugs accountable officer and regularly liaised with controlled drugs local intelligence networks. There were good links between the trust senior leadership team and pharmacy. Joint working with a local acute trust on digital systems meant that staff had read only access to blood and pathology results.

There was clear oversight of medicines risks and incidents. The medicines safety officer and medicines safety nurse reviewed medicines incidents. They regularly attended the medicines safety group and patient safety involvement group (PSIG). The chief pharmacist attended the weekly trust huddle, where learning regarding patient deaths was discussed. Strategic delivery groups (SDG) had oversight and ownership of medicines risk in their areas. The trust quality and safety committee had oversight of medicines incidents and action plans. Findings and recommendations from regular medicines audits were fed back to the appropriate SDG for review and action. The inspection of the acute mental health inpatient wards found some issues with medicines administration including PRN (as and when medicines) records not including a reason for or limits on administration, so that promethazine was administered above the British National Formulary daily limit. It also found instances when controlled drugs were administered with only one signature on Kahlo, Picasso and Knight wards. This indicated a need to review and strengthen the medicines audits. Pharmacy dispensing had, until recently been provided externally. This function had now moved inhouse, with the former providers staff transferring their employment to NELFT.

There were robust arrangements in place to ensure that the trust discharged its powers and duties under the provisions of the Mental Health Act 1983 (MHA) and Mental Capacity Act 2005 (MCA). The use of the MHA was overseen by the mental health legislation group, which was chaired by the chief nurse, who was the executive lead for the MHA and MCA on the board. The group met 8 times per year and reported to the strategic development group for care (SDGC). The board received assurance on the operation of the MHA and MCA through a quarterly report.

The trusts mental health legislation team was appropriately staffed and resourced. They provided training, monitored and managed the MHA and MCA over the trusts geography and supported associate hospital managers. They were also responsible for the electronic documentation system and Deprivation of Liberty Safeguards (DoLS). The team produced an electronic weekly MHA reminder list for all teams and chased First-Tier Tribunal and associate hospital manager hearing reports. There were 9 recorded unlawful uses of the MHA in the last quarter of 2023-2024 which was comparable to 2021-2022. Recent developments included the digitisation of paper MHA forms, the use of hybrid mail and the recently introduced electronic documentation system, which would ultimately enable the team to track MHA applications rather than scan paperwork onto their systems.

MHA and MCA training was mandatory for all clinical staff with a requirement for an annual refresher. The latest compliance rates were 86.01% for the MHA and 96.8% for the MCA. The trust also provided initial and update MHA training for approved clinicians and section 12 doctors, which it made available to other organisations, providing a source of income.

There were 17 associate hospital managers in post, with 8 having been recruited since 2020. There was a reasonable balance of gender and ethnicity although most were aged over 50. They included 2 ex-NELFT employees, a barrister and 2 solicitors. Seven were trained to chair hearings. Associate hospital managers were paid a fee to attend hearings, meetings and training. Hearings took place either face to face or remotely. There had been no recent discharges from detention by AHM panels. CQC MHA monitoring visit reports were received and distributed for response by the chief nurse with the issues raised being circulated to the mental health legislation team and relevant directorates. The most frequently raised recent themes were; consent to treatment; section 132 rights advice; documentation and recording assessments of capacity and competence.

The trust had arrangements in place to monitor its compliance with the Mental Health Units (Use of Force) Act which came into effect in 2022. The trust had a lead to oversee the work to monitor and reduce the use of restrictive interventions. The trust had published its policy and provided information for patients on their rights. The trust accessed training certified as compliant with the Restraint Reduction Network Training Standards. The trust monitored the use of restrictive practices in line with the NHS digital mental health services data set.

Both the chair of the audit committee/trust vice-chair and the chair of the finance and investment committee were accountants with significant experience in the leadership on public bodies. After a long period of financial stability, the trust had become exposed to turbulence which was impacting the delivery of its plans for financial sustainability. Its financial plan for 2024-25 required significant changes to deliver improved value, reduce its use of agency staff and out of area placements. It had struggled to achieve these improvements. The trust told us that it expected to achieve its financial targets in 2024-25 with support from the integrated care board.

The trust had a track record of delivering its financial plans, albeit in recent years through the use of accumulated funds. For 2024-25 the trust set a breakeven financial plan, after receiving £4.9m agreed funding to cover its planned deficit. It told us that it had experienced significant financial pressures in 2024-25. At the time of the inspection, it was reporting to NHSE that it expected to receive £651m of income for the year and was reporting a deficit of £10.6m, after receipt of a further £10m support from the integrated care board.

At the time of the inspection the trust was reporting that up to February 2025 it had spent £18.1m against a full-year plan of £14m on improvements to its estates, equipment and digital capacity. There had been an overspend on the St Georges Hub capital project by £6m, which was being met by the ICB.

The trust’s external auditor had stated that that the trust accounts for 2023-24 gave a true and fair view. They made no published specific recommendations in their value for money opinion on the trust’s arrangements for financial sustainability, governance and value for money. For 2023-24, the trusts internal auditor had given an opinion that ‘Significant assurance with minor improvement opportunities can be given on the overall adequacy and effectiveness of the organisation’s framework of governance, risk management and control.’ The chair of the audit committee told us they expected a similar opinion for 2024-25.

The trust had a dedicated estates team and strategy. Options for redevelopment of the Goodmayes Hospital site were being considered. Recent capital outlays included development of the St Georges hub and expansion of the integrated crisis assessment hub to facilitate its expansion to a 24-hour service. A programme to assess and address potential ligature risks in mental health inpatient settings was ongoing, but behind schedule. Overall, the trusts reserve was depleted.

Cleanliness on the wards, clinics and corporate areas were monitored by the facilities team. Inpatient wards were assessed annually through patient led assessments of the care environment (PLACE). PLACE scores had been adversely affected by poor environments at Sunflowers Court and The Woodbury Unit. The trust was a tenant at these sites and was working closely with the landlord to address issues.

The trust had a digital information and cyber security team. Their digital strategy was developed in 2022. The trusts digital lead and their team demonstrated a good understanding of what was needed to improve staff access to IT and to support patients to use IT to improve their access to trust services. The trust was on track to rollout improved WiFi access across all sites. The digital team were confident that delivering the digital strategy would bring long term financial savings. The team were open to tackling challenges with innovative thinking.

During part of 2024 the trust was in enhanced surveillance through the North-East London integrated care system quality surveillance committee. This was in response to a number of coroners prevention of future death reports. This was monitored through monthly meetings with an action plan to address the themes coming from the reports. This enhanced surveillance ended in October 2024 when the integrated care system felt that the trust had appropriate arrangements in place.

The trust board recognised the importance of its partnership working. This included engaging with integrated care systems; place-based work including primary care, social care and third sector providers; and provider collaboratives. Feedback from system partners noted that the current trust leadership was more open and willing to work with other providers than had previously been the case.

The trust had an executive director of partnerships. There was oversight and governance of the partnership arrangements through the partnership and integrated care sub-committee of the board. This reported on collaborative working and provided assurance that the appropriate arrangements were in place.

The organisation of the trust into geographically based directorates meant leaders were involved in partnership working at a system level and at place. This included the development of the North-East London mental health learning disability and autism collaborative which had been pioneering the inclusion of leaders with lived experience. The trust were also active participants in the community health services collaborative in North-East London and Mid and South Essex. An example of this partnership work was the North-East London collaborative improvement network where the trust had shared their quality improvement methodology to address waiting lists of talking therapies and tackle unwarranted variation. Another example was in Mid and South Essex where they had delivered teams to provide an urgent community response for people with physical health needs who were at risk of being hospitalised. These teams were seeing over 75% of the people referred within two hours and reducing their need to attend local emergency departments.

There were many examples of the trust working in partnership at place to meet the needs of the local population and address inequalities. For example, in Barking, Havering and Redbridge the trust had developed a children’s and young people autism pathway. This had been developed in partnership with the Cambridge University Autism Research Centre. This had delivered waiting time reductions of nearly 80% while taking a holistic needs-based approach.

Another example in North-East London was the collaborative work between the trust, metropolitan police and local communities to improve crisis care for people with mental health needs. As part of this work there had been a conference of over 70 people including trust staff, involvement representatives and local community organisations such as the association of Redbridge African Caribbean communities (TARACC).

One further example in Southend, Essex and Thurrock was the development of tools to measure the impact of mental health input for schools. In partnership with the local authorities the trust was developing self-harm toolkits. They were also working with educational psychologists across Essex to develop a series of workshops available to all schools accessed through the Essex County Council website.

Various Healthwatch teams told us that they engaged with the trust on an ‘ad-hoc’ basis. They had been consulted around strategy and some other co-production. Healthwatch teams fed back that they found trust staff to be approachable and professional. There was concern around wait times to access a number of services, particularly wait times in ED to access a mental health bed; wait times to access a memory clinic for dementia assessment and the appropriateness of crisis SEND assessments in ED. One Healthwatch team commented that it was of some concern that the trust was spread so widely over such a large geography. Havering Healthwatch feedback that its local respiratory/pulmonary and rehabilitation services were thought of highly.

The trust had more than 10,000 public members who were kept informed about NELFT’s work and future plans for healthcare services in their area. The recently appointed member of the corporate governance team was focusing on supporting the governors and developing the work with members.

There were section 75 agreements in place between NELFT and Havering, Redbridge and Waltham Forest. All approved mental health professionals (AHMP) worked across boroughs to assess their own residents. One section 136 suite served the trust at the Goodmayes hospital site. This could be busy or used for seclusion or damaged by patients, which impacted on the number of assessments that could take place there. Eighty MHA assessments took place at Goodmayes during 2024, compared to 180 at Queen’s Hospital. There was a dedicated AMHP at Whipps Cross with recruitment in progress for dedicated AMHPs at Queens Hospital/King George’s and Sunflowers Court. No problems were reported obtaining section 12 doctors or with transportation. All 4 London boroughs joined together to organise flexible AMHP refresher training. AMHP leads attended NELFT’s police liaison group meeting, along with representation from the trusts mental health legislation team and police, to review the use of section 135 warrants and section 136. Concerns were expressed by AMHPs about consent when executing a s135(1) warrant at a patient’s home and the convenience of using electronic records whilst in the community for MHA assessments.

The trust had identified that its safeguarding approach required strengthening and improving. In response to national safeguarding children practice reviews, NELFT commissioned an independent review of its safeguarding services which was completed in May 2023. This identified the need to strengthen and improve several key areas including; safeguarding leadership; assurance; governance; training; capacity, risk; operational delivery and compliance with ‘Working together to safeguard children’. In addition, concerns were raised by the north east London integrated care board (ICB) in relation to; safeguarding workforce; safeguarding governance and the consistency and timeliness of escalation. The ICB conducted its own review into these concerns.

As a result of these reviews an improvement plan was developed. The trust strengthened its safeguarding team and infrastructure to ensure statutory responsibilities were met and ensure safeguarding remained a priority across all services. The trusts safeguarding strategy is due for review in 2025.

The trust had appropriate links with safeguarding boards and child death overview panels within their geography. They contributed to serious case reviews and level 4 safeguarding investigations when required. Trust wide compliance with safeguarding training was 96%. Significant improvements had been made in relation to safeguarding supervision during 2023/24 and trust wide compliance was above 75%.

The trust had a process to respond to complaints from people using services. We met with the trust complaints team and reviewed 5 complaints. We found systems and processes to deal with complaints needed strengthening. The trust was aware of this and was taking action to improve. The trust operated a centralised PALS team which reviewed complaints and decided whether they should be routed to local resolution or to a formal complaints process. Where a formal complaint process was instigated, an investigator was allocated; terms of reference were agreed with the complainant; an investigation was completed; outcomes were conveyed to the complainant via letter and, if appropriate, an action was developed.

Investigators received training to carry out their role. For most complaints the trust aimed to complete investigations and respond within 5 weeks. Where complaints were complex, investigators would agree an appropriate timescale with the complainant. Complainants were able to access support from advocacy services.

At the time of our assessment, the trust had met its five week timescale in 66% of formal complaints. This was attributed to delays in identifying an appropriate investigating officer with capacity. Themes from complaints included concerns about wait times to access services, particularly community child and adolescent mental health services and attention-deficit/hyperactivity disorder (ADHD) services. There were also a significant proportion of complaints relating to care planning in community adult mental health services.

The complaints team reviewed investigation reports and response letters to complainants, which were authorised by the chief executive. Processes were in place ensure learning from complaints was shared. The sample of complaint responses we looked at demonstrated the trust understood duty of candour and were open and honest with patients. The complaint investigations we saw were comprehensive and fully addressed the concerns raised. Complaint response letters contained sufficient information.

An external auditor had reviewed the trusts complaints process in 2024. Their findings were presented to board in December 2024. They found that improvements were needed in a range of areas to strengthen governance systems in relation to complaints. These recommendations were adopted by the board with actions developed and in progress at the time of our inspection.

The trust was working hard to develop a collaborative approach with people who used services in their design, delivery and evaluation. There were 327 registered involvement representatives with lived experience involved with co-production across the trust. This included 86 young adults. In 2023 involvement representatives contributed 7,837 hours of their time to the trust. The trust was continuing to recruit involvement representatives.

Each locality held monthly integrated patient and carer panels and young adult network meetings. Feedback from these meetings was taken by involvement representatives to strategic patient and carer engagement panels which held a trust wide brief. In 2023 the trust had established two patient leadership roles to support and consolidate patient participation.

The trust had made significant progress in ensuring the patient voice was central in training delivered to staff. In 2023/24, nearly 65% of trust wide learning had service user involvement. Risk assessment and management training being rolled out to all staff across the trust at the time of our assessment and could not be delivered without a patient participation representative. The trust board routinely heard feedback from people who use services. At each board meeting they heard a ‘patient story’ directly from people who used services or their carers’.

At the time of our assessment, mandatory training compliance across the trust was 92%. Supervision and appraisal compliance rates were 76% and 77% respectively, trust wide.

The trust had a well established research department. At the time of our assessment, in addition to the department head, there were 38 staff attached to specific research projects. The trust encouraged staff from a range of backgrounds to engage in research and supported them with the skills to do this. The trust typically focused on psychosocial interventions rather than pharmacological interventions in its research programmes. An annual research conference was promoted by the trust and was well attended. A regular training programme for staff interested in developing research skills was run throughout the year. Journal and PhD clubs were also facilitated.

The research department was a net contributor to trust finances and was self-funding. At the time of our assessment, 44 portfolio and 16 non-portfolio studies were running. Examples of portfolio studies included: ‘No-one left alone’, support for people recently diagnosed with dementia; implementation of open dialog after a 7 year study; HARP, communication skills for people with aphasia; compassion focussed therapy, for people with depression and anxiety. Examples of non-portfolio studies included setting up a skate-boarding group for young adults who might benefit from support whilst not meeting the criteria for commissioned mental health services.

The trust was working to develop and embed quality improvement (QI) approaches across teams and directorates. There was a dedicated QI team of 8 staff and an identified executive lead. The trust recognised that the use of QI methodologies was uneven, with corporate teams more likely to engage. For example, only 12 teams had engaged in the ‘Good days at work’ collaborative, none of these were clinical teams.

The QI team were committed and enthusiastic. Since we last inspected QI forums had been established in each directorate. Staff could bring their ideas to these forums and receive advice and support from the QI team. The trust had a QI strategy for 2023-2026. The key components were to develop vision, leadership, capability and capacity. There had been some notable successes, for example, a QI project on reusing laptops for new staff had saved the trust £35k.

In the last year, 107 new QI projects had been registered across the trust. Of these, 58 included service involvement and a further 18 were co-produced with people who used services. A further 40 included some element of consultation with people using services. The trust had won a Health Service Journal (HSJ) highly commended award for a QI project focused on services closer to home for people with a laryngectomy.

Pharmacy staff had been recognised for several innovations. For example, a HSJ award for the creation of an operational dashboard which helped prioritise workload. The pharmacy team had also been short listed for a British Geriatric Society award for a QI project on frailty; which looked at safer prescribing and reduced hospital admissions. Other examples included: deprescribing of benzodiazepines in the home treatment team.

The trust was committed to delivering a comprehensive clinical audit programme (CAP) aimed at improving quality of care. The trust clinical audit NICE (CAN) team facilitated the trusts clinical audit programme. During 2023/24, NELFT participated in 10 national clinical audits and 1 national confidential enquiry into patient outcome and death (NCEPOD). A total of 44 local clinical audits were registered trust wide in 2023/24.

The trusts mortality review group (MRG) was responsible for reviewing and learning from deaths, aiming to improve patient care and reduce avoidable mortality. The MRG reviewed data on patient deaths, including local mortality reviews, to identify patterns and trends. The MRG provided assurance to the trust board and other relevant bodies on patient mortality based on the review of care received by those who died. At the time or our assessment, the MRG had not met as scheduled for several quarters. The acting chief medical officer was sighted on this and taking steps to address the backlog of around 60 cases for review and to ensure the reintroduction of regular MRG meetings.

The trust had systems in place to learn from the deaths of people with a learning disability or autistic people (LeDeR) who were receiving services from them. Learning from LeDeR reviews was shared across the trust and with other partners to help reduce the health inequalities for people with a learning disability or autistic people.

The trust had moved to the patient safety incident response framework in June 2023. This was in line with NHS England guidance on how to respond, learn and improve patient safety. Since our last inspection the trust had also introduced an updated electronic incident reporting system and significant resource had been deployed by the corporate incident reporting team to support staff with this transition.

Robust governance procedures underpinned the trusts PSIRF approach. A patient safety incident group (PSIG) had been established trust wide to share and disseminate learning. People who used services were represented at each PSIG meeting. There were 8 local priorities identified by the trust. These were:

• Homicide in mental health and specialist services
• In-patient deaths/or suspected suicides in mental health and specialist services
• Unexpected deaths in community mental health services,
• Unexpected deaths in community child adolescent mental health services and community health services.
• AWOL/absconsion whilst detained under the Mental Health Act
• Falls/fractures in community health services, mental health and specialist services
• Overdose of prescribed/non prescribed medication and severe harm in community health services, mental health services, community mental health services and mental health inpatients
• Pressure ulcers (category 3+) developed whilst receiving care.

A total of 78 incidents had been raised through PSIG for the period 1 June 2023 to 13 March 2024. These included after action reviews, swarm huddles, patient safety incident investigations (PSII), and multidisciplinary reviews addressing themes such as young peoples suicide and pressure care.

The trusts most recent harm free care report was presented to board in January 2025. Since our last inspection, the trusts governance process to investigate, act and learn from pressure care incidents had been reviewed and updated. Locality teams carried out initial reviews/investigations into pressure ulcers. Their findings were presented to a trust wide multidisciplinary panel. Findings from this panel, along with the findings of any patient safety incident investigations (PSII) that identified pressure care issues, fed into a trust wide pressure ulcer action plan. A bi-monthly trust wide pressure ulcer assurance group kept this action plan under review and maintained oversight of any thematic reviews underway that related to pressure care. The trust had developed a ‘great skin’ resource pack for people using services and was developing its training for staff to address skin tone bias when assessing pressure care areas that could lead to health inequalities.

The trust had a dedicated infection prevention control (IPC) team. They last reported to the board in July 2024. The team provided advice to teams or individual staff and also provided trust wide IPC governance. A range of audits had been completed to monitor and review compliance with hand hygiene, decontamination, catheter care and peripheral lines. Trust wide, IPC mandatory training was above 90%. The team had led a trust wide QI project promoting aseptic non-touch technique (ANTT).

The trust had won a number of awards in 2024.

The trust acknowledged the challenges ahead in their journey towards net zero. An understanding of their current position, plans to obtain additional funding to support their journey as well as a refreshed green plan, indicated a sound foundation from which they could progress.

The trust had a green plan, published in 2022, in line with national guidance. This was due to be updated following the publication of refreshed guidance by Greener NHS. The trust had identified that its updated green plan would need to be structured to ensure progress could be tracked and leaders would be held accountable. Sustainability was reported annually to the board.

Leaders recognized there had been challenges in engaging staff across the trust and that there was more to do in this area. Leaders were concerned that staff may not be aware of net zero goals or their role in contributing to these. There were plans to make educational resources addressing sustainability across the trust available to staff. The trust aimed to develop quality improvement projects that promoted sustainability and was aware of the need to focus on efficient models of care.

There were active projects within the trust that, as an unintended consequence, were cutting emissions and promoting sustainability. For example, the chief executive was leading a campaign around ‘wasting less’.

The trust had engaged with and contributed to the north-east London integrated care board green plan. Examples of the trust’s contribution included a more sustainable approach to procurement and medicines. The trust reported data nationally in respect of their individual emissions and had made commitments to national initiatives to reduce emissions addressing medicines, estates and procurement.

The trust was introducing new ways of working that reduced their carbon footprint. For example, an increased use of digital records. The recent introduction of in-house electronic prescribing was estimated to have reduced medicines waste and financial costs by an estimated £100k.

In planning for the future, the trust had made national funding bids to support its sustainability aims. Training for staff was being developed so that sustainability impact could be considered as part of future cost improvement programmes.