Liverpool University Hospitals NHS Foundation Trust Also known as Aintree University Hospital NHS Foundation Trust - formerly

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

Staff and leaders demonstrated a positive, compassionate, listening culture that promoted trust and understanding between them and people using the service and was focused on learning and improvement. The trust had a strategy and plan for delivery which covered the period between 2021 and 2024. Liverpool University Hospitals NHS Foundation Trust and Liverpool Women's NHS Foundation Trust established a Group Board on 1 November 2024. Whilst the new Group strategy, vision and values were being developed an improvement plan was in place to provide the strategic direction.

The improvement plan for the period 2022 to 2025 focused on improving the organisation in the short to medium term and was underpinned by key success measure for each of the stabilising, performing and transforming phases. Phase two focused on six areas; Well-led, People and Culture, Quality and Safety, Clinical Effectiveness, Financial Stability and Operational Performance. A transformational delivery unit had been established to provide a deliverable roadmap for change; manage the delivery of the improvement plan; support communication and engagement in the plan and focus on outcomes. This provided the board with data, metrics, trends over time and assurance resulting in a more streamlined and focused plan.

The Trust's existing vision was still in place:

• Our vision is shared by our partners: we work together to support our communities to live healthier, happier, fairer lives. 
• It draws upon our shared foundations of passion and pride in our roles, a desire to provide great care, community spirit and teamwork, and a willingness to speak up for what we believe in. 
• Our mission is clear: by working together we will deliver outstanding healthcare.
• We are working together with our partners and with the communities we serve, to deliver our strategy. To succeed, we are listening and to do things differently, living the values that form our culture of being caring, fair and innovative.

The trust's well-established values from 2021 also remained in place; we are caring, we are fair and we are innovative.

The trust had processes in place to identify and address behaviours that were inconsistent with the values of the NHS. We reviewed three examples of grievance, and all had been completed in line with the trust's process. Processes to ensure staff remained fit and proper for their roles were in place and there were staff rechecks of external bodies such as the disclosure and barring service.

The trust used a variety of methods to engage with people including in-person events, social media, and electronic surveys as well as working with Healthwatch. Events for people to contribute to the new Group strategy had not yet been held. Survey results from people using the trust's inpatient departments showed mostly positive results in relation the trust's culture. People felt staff supported them and listened to them. The emergency and outpatient department surveys displayed a range of experiences including positive and negative interactions with staff. The trust's governors were positive about the trust's culture and described their experience of working with the trust as open, honest and transparent.

Leaders could describe the trust's existing vision and values and the phase two improvement plan and their responsibilities within it. They could provide examples of meaningful change as a result of the action plan and the milestones that had been achieved as a result. For example, the work undertaken across the trust to assess delirium in patients by introducing a new assessment tool, facilitating staff training and regular review of progress and outcomes.

Leaders were fluent with the system to monitor and review progress against the improvement plan and the suit of data and metrics underpinning it. They could describe progress against the deliverables for areas they were involved with and how this was implemented at a local level.

The trust and its leaders understood the challenges to delivering the improvement plan and understood the health and care inequalities across local system and population it serviced. They had undertaken an analysis of the local population health and care needs and recognised that they needed to work together across the health and care sector for future improvement plans to succeed. There was a plan in place for the trust to improve population health and reduce health inequalities, to embed prevention and equity, and fulfil its role as an Anchor institution.

Staff and leaders were very positive and proud to work at the trust, and most staff could describe the trust's existing vision and values. Staff understood the importance of equality and human rights in their work and could provide examples of where they had supported individuals with this. The trust had an Equality, Diversity and Inclusion Plan 2023 to 2026 which set out the commitment to address inequalities for patients, the communities it served and colleagues the trust worked with.

Leaders were positive about the trust's culture and recognised how this was improving across the sites and staff groups. Leaders consistently demonstrated their commitment to compassionate and inclusive leadership through leading by example and supporting others to develop. The NHS staff survey results from 2023 reported the trust score was lower than the national average for questions relating to staff culture with the lowest scores were attributed to the nursing and healthcare assistant groups who may have felt relationships were more strained more often than other staff groups. The latest National Quarterly Pulse Survey results showed that the trust scores for staff engagement were improving.

Feedback from partners was consistently positive and all agreed that the trust met the description of the shared direction and culture quality statement.

The trust provided examples of how partners had engaged and contributed to the improvement plan and how it aligned to the objectives and priorities within the local system. Partners had confidence that the trust could deliver the improvement plan and could describe how progress and results were monitored.

Partners were aware that the trust was developing a new strategy, vision and values as part of the group work but had not yet had the opportunity to contribute to it as development was still in the early stages.

Partners described an open, transparent and learning culture at the trust that had notably improved over the last three years. Partners could describe the journey the trust had been on to improve culture across the sites and how leaders acted as role models.

Leaders had the experience, capacity, capability and integrity to ensure that the organisational vision could be delivered and risks were well managed. Since the last inspection of the trust in 2021 a new group board and senior leadership team had been established to develop leadership capacity and capability for the future. The trust’s board comprised of thirteen directors who attended board, of which 9 were voting members of the board, the chief executive and nine non-executive directors including the trust’s chair. A number of executive roles were recruited to in 2022 including Chief Executive Officer, Chief Medical Officer, Chief Nursing Officer and Chief People Officer. All recruits had previous experience of working in similar roles in other NHS Trusts. A Chief Strategy and Partnerships Officer was appointed in 2023. In addition, two Executive Managing Directors of Operations were appointed to strengthen ward to board reporting across the sites, a Chief Digital Information Officer to improve the digital strategy and a Chief Transformation Officer to lead the transformation delivery unit and embed the improvement plan. A new chair of the trust was appointed in 2023 and the non-executive team had more newly appointed directors to enhance capacity and balance the board. The executive team held a range of individual portfolios covering areas including being well-led, people and culture, quality and safety, clinical effectiveness, finance and sustainability and operational performance.

The trust had a board development programme and plan in place; with some sessions being facilitated by external agencies to promote a unified board. Sessions focused on areas identified for developing a new board and included how to access and read statistical process control data, strategy development and maintaining good visibility of quality and performance whilst devolving accountability to hospital sites. Leaders we spoke with were knowledgeable about the issues and priorities affecting the quality of services and recognised their role supporting improvement.

During our assessments across medicine and emergency and urgent care most staff told us leaders were visible within the trust.

The executive and non-executive team undertook regular structured safety walk arounds to services across the trust. There were also regular visits by members of the hospital leadership teams. In addition, there was a structured visiting programme for non-executive directors and governors.

The visits were planned in advance and observations written up and shared at hospital management and board meetings. Staff told us how this assisted with leadership visibility and created an opportunity to share best practice. Examples were provided where experience was shared that led to improvements. For example, changes to an environment to promote accessibility. Leaders told us the visits provided greater understanding of how services worked, provided an opportunity to engage directly with staff and patients and triangulate the information received through the trust’s governance systems. Up to January 2025, 151 service visits had been undertaken to areas including medicine, surgery, facilities and laboratories.

The trust’s board described themselves as diverse in skills and experience and lived experience of using services. The culture of the board was described as compassionate, inclusive and collaborative. The Culture and Leadership Strategic plan described the enhanced leadership framework and development programmes and focused on the trust’s value to underpin the behaviours modelled by its leaders. Leaders could describe succession planning within the trust. They had identified areas where succession planning would require additional or external support.

The enhanced leadership framework focused on embedding people’s skills and knowledge and aligned to the operating framework. The framework outlined the roadmap to effective leadership at the trust and clarity on the desired competencies, values and behaviours that would positively influence trust culture, patient and employee experience and drive organisational excellence. It provided leaders and aspiring leaders with the necessary resources, tools, opportunities and support to facilitate growth and success. During our assessments of medicine and urgent and emergency care we spoke with staff who gave positive feedback about developing their leadership skills through the framework. Staff working at the trust accessed the Elevate programme which was a bespoke leadership course in partnership with neighbouring NHS trusts to enable staff from ethnic minorities to progress and realise their leadership aspirations.

Leaders were able to share examples of current or historical poor culture across the sites that may have affected the quality of people’s care and have a detrimental impact on staff. They could describe the actions that had been taken to address this.

Following external review feedback, succession plans were in place for members of the executive team and work was in progress to strengthen this providing opportunity for others.

Partners told us the leaders had the experience, capacity, capability and integrity to lead the organisation and ensure risks were identified managed well. They could provide examples of working in partnership with the trust to improve services delivered to patients.

Fit and proper persons checks were in place for all directors in line with the requirements of the regulation. All files we reviewed showed the trust had completed appropriate checks of board and executive directors’ suitability for their roles. All had received an annual appraisal within the previous year.

Staff and Leaders actively promoted staff empowerment to drive improvement. Leaders encouraged staff to raise concerns and promoted the value of doing so. Leaders told us that historically staff tended to report their concerns about working at the trust externally, rather than internally. Leaders could demonstrate that they received less feedback from external sources about staff experience, particularly over the last two years.

The trust had a freedom to speak up, raising concerns and whistleblowing policy which had been reviewed in May 2023. The policy had been updated to reflect changes in guidance from the National Guardian’s Office. The dedicated Freedom to Speak Up guardian role was supported by 58 Freedom to Speak Up champions across the trust sites. They did not have access to administrative support and told us this was being considered. Some issues raised were signposted to other departments for resolution and were not always captured in the reporting. The freedom to speak up guardian and champions met monthly with one meeting per quarter dedicated to a team development session. Topics included how champions could support their own workplace team culture and enhance team psychological safety. Freedom to speak up champions contributed to a variety of additional roles to develop their own knowledge and skills which included contributing to the policy working group and patient safety incident response framework, offering an alternative to staff exit interviews and supporting with task and finish groups.

All staff were required to undertake freedom to speak up awareness training with 91% compliance across all sites in March 2024. Further training resources were available to managers and leaders across the trust which included elements on listening and acting upon negative or constructive feedback.

The freedom to speak up guardian reported into the Chief of People executive officer and a named non-executive lead at board level. In October 2023 the board completed the NHS England Freedom to Speak Up planning tool to align it to the trust improvement plan and construct the annual plan. The trust board received a bi-annual (six-monthly) report into freedom to speak up reporting progress against the annual plan. Each of the hospital leadership teams completed a reflection tool as part of the reporting into board once a year. This supported local leaders and managers to review the speak up culture at site level.

The latest National Guardian’s Office report showed the numbers of staff raising concerns via the trust’s freedom to speak up process was comparable to the previous year. Across Q1 and Q2 2024/25 a total of 89 cases had been reported through freedom to speak up. When compared with similar trusts in the North-west region, the trust had the fourth lowest number of cases raised in this period. Of the 89 cases raised, 59 were primarily about worker safety or wellbeing, 22 were primarily about bullying or harassment; both of which were the second highest totals for these elements across the region for the same period. .

Staff reported they felt more recently able to speak up within the trust. The 2023 NHS Staff Survey showed that 59.95% of staff agreed the statement ‘I feel safe to speak up about anything that concerns me in this organisation’. This was slightly lower than the national average of 60.89% and improvement seen on the trust’s 2022 score of 55.75%.

The NHS Staff Survey showed 47.31% of staff agreed with the statement ‘If I spoke up about something that concerned me, I am confident my organisation would address my concern’. This was an increase on the trust’s 2022 score of 41.11% but slightly lower than the national average of 48.65%.

Leaders told us they encouraged staff to speak up and raise concerns and made reference to it in everything they did rather than talk or refer to it separately. They described this as using the language of speaking up, listening and ensuring matters raised were followed up and resolved. Leaders demonstrated awareness and knowledge of how to facilitate psychologically safe environments for people to speak up without being reminded or prompted to do it.

Staff we spoke with during our assessments told us they knew how to speak up and over the past two years were encouraged more to do so. They could provide examples of their experience when speaking up and subsequent outcomes. There was the opportunity for staff who raised their experiences to become experts by lived experience and contribute to improvements in processes and procedures.

Members of the board undertook regular formal visits to areas throughout the trust to engage with staff and listen to their experiences about working for the trust. At the time of assessment, the trust was considering whether people could contact Freedom Speak Up anonymously, and this was being explored sharing experiences with another trust that had this in place and the tools that would need to be in place in order for staff to do so.

Partners reported the culture had recently improved over the last two years encouraging staff to speak up. They had received less contact from staff raising concerns outside of the trust as a result of the improvement in the process internally. Partners were confident that leaders would take effective action to address concerns.

The trust monitored equality, diversity and inclusion in line with the NHS Workforce Race Equality Standard. The most recent report described Ethnic diversity in staff groups (17.4%) was lower than the national average (26.4%). Diversity in the trust board was 33% which was higher than national averages. Since the report was published the number of non-executive and executive directors had increased across the Group model which affected the trust board’s diversity. The board were aware of this and non-executive directors and the Chair could describe how they worked closely with trust governors’ who shared their lived experiences and were more representative of the local population. White staff represented 64% of staff at non-clinical management grades at band 8c or above. There was slightly less diversity in clinical management grades at all bands.

The trust had processes to monitor, and act when required, on fairness in recruitment and career progression for staff in equality groups. The WRES metrics for 2023 showed white staff had a higher likelihood of being appointed from shortlisting compared to staff from equality groups. Metrics for disciplinary and capability processes showed staff from equality groups were more likely to enter disciplinary processes than white staff. There was no difference in the likelihood of white staff accessing mandatory training compared to staff from equality groups.

Leaders were taking action to improve disparities in the experience of staff with protected equality characteristics, or those from excluded and marginalised groups. The trust scored worse than the national average for 2 of the 4 WRES metrics in the 2023 NHS staff survey. This was for staff from all other ethnic groups combined, indicating worse experiences for these staff members when compared nationally for both: staff experiencing bullying and harassment from staff and experiencing discrimination at work from a manager or team leader. White staff at the trust scored better for 3 of the metrics, indicating less positive for staff from all other ethnic groups when compared to white staff. This was in line with national trends.

Processes were also in place to monitor workplace and career experiences of disabled and nondisabled staff. The Workforce Disability Equality Standard (WDES) metrics compared the workplace and career experiences for disabled and non-disabled staff. The trust performed worse than the national average for 3 of the 7 WDES metrics from the 2023 NHS staff survey, which indicated worse experiences for staff with long term conditions or illnesses at the trust when compared nationally. Areas identified with less satisfaction for staff living with a disability were: opportunity for career progression, experiencing bullying and harassment and access to reasonable adjustments. However, staff without a long-term condition or illness scored better in all 7 of the metrics, indicating less positive experiences for staff at the trust with a long-term condition or illness compared to those without. The trust had recognised a deterioration in this area and were refocussing the EDI strategy and plan. The priorities were updated to include a focus on staff experience living with a disability to respond to the emerging insight.

Compared with other trusts, staff colleagues experiencing discrimination on the grounds of sexual orientation and disability was slightly worse than national averages. In 2023, 5.88% experienced discrimination on the grounds of their sexual orientation, with the national average at 4%. There was 10.84% who experienced discrimination on the grounds of disability, which was above the national average of 9.01%, however this was a decrease from 12.35% in 2021.

The trust performed worse than average in comparison to all other trusts for questions relating to culture and treatment from other members of staff. The lowest scoring staff group at the trust was nursing and healthcare assistants with 62.5% and 62.4% respectively. This was also the lowest scoring staff group for these questions for all acute and acute and community trusts nationally excluding ambulance (operational) staff. However, all questions were demonstrating an improvement in the trend overtime. For example, in 2023 compassionate culture overall scored 6.91 compared to 6.54 in 2022.

The trust had an action plan to address the indicators with improvement identified in the WRES and WDES reports. Progress against the action plan was monitored by updates to the board through the People and Culture Programme Board and Improvement Plan Portfolio Board. This included enhancing the training and support for managers supporting staff with reasonable adjustments. Leaders recognised whilst recent improvements had been made, a lot more work was required in this area.

The trust monitored gender pay gaps and the board received an annual report. The data for 2023 was better than public sector averages, it showed the trust’s gender pay gap had decreased slightly since the previous year. Further analysis indicated the greatest difference was experienced across medical grades where there was a higher number of males employed.

Several staff networks were in place to promote equality, diversity and inclusion. These were the Ethnic Minority Network, Inspiring Women’s Network, LGBTQ+ Network, Neurodiversity Network, Ethnic Minority Nurses Forum, Ethnic Minority Doctors Form and Culture Network. Each staff network had an executive sponsor. Feedback from the networks indicated the executive sponsors were engaged with the networks and listened to staff’s experiences. Staff generally felt able and empowered to speak up. Staff did report that they did not receive protected time to support the facilitation of network engagement and events, and it was sometimes undertaken in staffs own time.

The people and culture section of the trust improvement plan, led by the Chief People Officer focused on ‘making Liverpool a hospital of choice to join and then thrive in your career’. Leaders told us equality, diversity and inclusion was the focus of board development and a key priority for the trust. The trust had an Equality, Diversity and Inclusion Strategic plan 2023 to 2026 which set out a commitment to address inequalities for patients, the communities the trust served and colleagues worked with. Areas for improvement included:

• Values based training for recruiting managers
• Embedding cultural intelligence through education and training, eliminating racism and bias in practices as part of the LUHFT Anti-Racism programme
• Training and guidance and an accessible toolkit to support mediation
• Elevate Leadership Development programme for Black, Asian and Minority Ethnic staff
• Reasonable adjustments workshops for managers supported by occupational health and psychology services
• Sexual safety training for staff which considers the broader context of race and disability discrimination

The trust also recognised the challenges new colleagues from overseas may face when coming to work and move to the local area. The faculty of ‘Scouse school’ was developed as a way of welcoming overseas staff and provide them with the support to facilitate integration in their new workplace and the city of Liverpool. It included learning about Liverpool; its history, accents, vocabulary, pop culture, food and drink and guided tours to explore the trust sites and city. As a result, the trust had received national commendations for the work undertaken in this area, promoting inclusion and sense of community. Newly recruited staff at other trusts in the local area were also invited to join the faculty, enabling networking across the trusts.

Partners told us the trust embraced equality, diversity and inclusion. They felt the trust actively promoted equality, diversity and inclusion both internally and within the local system. Partners were aware of the trust’s staff equality, diversity and inclusion networks. Partners were positive about the commitment demonstrated by leaders to supporting equality, diversity and inclusion.

In our survey of partners in stakeholder engagement events, we received mostly positive feedback in relation to this quality statement.

Governance

The governance, management and accountability arrangements had changed since the last inspection and a new board and senior leadership team had been appointed. The trust’s governance and board assurance model had been redesigned. Leaders understood their role and responsibilities. A new risk management approach was launched, an improvement plan linking into the strategy and a transformation delivery unit had been established.

The trust had also commissioned an external review of the well-led key question which was completed in September 2023 by Deloitte. The external review recommended strengthening succession planning across the executive team, monitor committee capacity and chairing responsibility and executive oversight in the absence of an executive review forum, and clarity of the expectations regarding the relationship between autonomy, performance and intervention. Oversight of the recommendations was reported into the trust’s former Assurance and Risk Committee. Progress reports were provided at the November 2023, January 2024 and April 2024 meetings. The reports confirmed implementation of all of the external’s review recommendations.

The trust four board level committees were:

LUHFT Audit Committee

Group Strategy and Partnerships Committee

LUHFT Renumeration Committee

LUHFT Charitable Funds Committee

Hospital Management Boards at site level were formed in April 2023with each one reporting direct to the trust’s board via the site executive directors of operations. The trust’s governance structures, systems and processes had been designed to reflect this approach. To ensure consistency across the organisation, each management board and its four oversight groups had terms of reference in common and were supported by the corporate governance team. In addition, there was also a LUHFT Improvement Plan Portfolio Board. Frameworks had been updated to reflect changes to governance structures. As part of the establishment of University Hospitals of Liverpool Group in November 2024 the Liverpool Women’s Hospital, Hospital Management Board was formed and joined the group.

Whilst this governance structure was different to most other NHS trusts, in that there were no trust board level committees to review areas such as quality, people, performance, at the time of the inspection, it appeared to be working well. The structure was established in April 2023 and at the time of inspection had gone through a cycle of 20 months of meetings.

However, further evidence would be required to be assured that the model was both embedded and effective within a group model structure. The trust were working with NHS England who were undertaking a review of the group model at the time of inspection.

The trust board had agreed an assurance structure which supported site hospital management boards to enable hospital leadership teams to focus on the day to day running of each site with delegation for decision making. This provided devolved control of aspects that affected the running of the site and leaders ability to respond. Each hospital management board had the same four oversight groups that consisted of quality and safety, people and organisation development, clinical effectiveness, research and innovation and finance and performance. The hospital leadership teams were led by an Executive Managing Director who represented each site and was a trust executive board member. Other site team members included a director of operations, medical director, director of nursing, a director of people and director of finance. They were joined by divisional directors and leads for corporate services to make up the hospital management board. Five rules of engagement were established, in response to the well-led external review, to retain a ‘one organisation’ approach which meant that hospital leadership boards could make their own decisions within an accountability framework. By working through the five rules of engagement any unintentional consequences on the wider organisation could be identified and escalated for Group wide consultation and agreement.

The five hospital Management Boards were established as part of the Group model:

• Aintree Hospital Management Board
• Broadgreen Hospital Management Board
• Royal Hospital Management Board
• Liverpool Clinical Laboratories Management Board
• Liverpool Women’s Hospital Management Board

Non-executive and executive directors were clear about their areas of responsibility. Each committee of the board was chaired by a non-executive director and supported by one or more non-executive directors as members.

Papers for board meetings and other committees were produced and circulated by the corporate services team which promoted consistency in the layout and format. They were of a good standard and contained appropriate information with a summary available at the beginning of board papers to identify key themes and recommendations.

The trust had systems to monitor compliance with mandatory training, supervision and appraisal. Mandatory training compliance was in line with the trust’s target, role specific training was slightly below the target of 90% at 88.67%. Supervision and appraisal rates were in line with trust’s target. Partnership arrangements were in place for the provision of psychiatric liaison services and regular meetings took place with partners to review performance and improve ways of working collaboratively.

Partners described good working relationships with the trust and could describe the systems in place to manage current and future performance and risks to the quality of the services.

Where cost improvements were taking place there were arrangements to consider the impact on patient care. Leaders monitored changes for potential impact on quality, equality and sustainability. There were processes to manage the financial sustainability of the trust and to assess potential impact on quality and equality from service changes.

Information Management

The board and hospital management boards received detailed integrated performance reports at corporate service, trust wide and hospital site level demonstrating performance against the improvement plan and other metrics as part of the trust board assurance model. Performance data and related assurances were produced through detailed statistical process control (SPCs) information by the transformational delivery unit who worked closely with the improvement senior responsible officers to capture the data and reporting required. Minimal variation to trends in reporting were captured and reported on. Executive and non-executive directors had access to the real time reporting data as well as the reports produced.

The trust had systems to ensure the trust board’s and hospital leadership teams received relevant performance data. The board received an overall heat map that provided a visual breakdown of the improvement plan areas against overall attainment, quality, performance and finance benefits and risk and issues which was rated red, amber, and green. Detailed analysis of the risk and issues were reported which included a description of the controls in place and last review date along with updates about the commentary on the key focus over the last period and for the next period. In depth detailed analysis of performance against the improvement plan areas was available that detailed trends overtime and emerging changes to data that could be a cause for concern. Leaders told us how detailed statistical analysis of metrics enabled them to maintain oversight of quality and performance and variations in the data and metrics were identified for further in-depth analysis and review and corroborated with information held in the trusts other databases.

In addition, the board received performance data within specific reports which were presented in line with the board’s business cycle. For example, the board received a quarterly guardian of safe working update which was presented at the January 2025 board meeting.

We saw, through site based local quality and safety meetings, the systems in place to share data and dashboards with staff to support them in the process of daily continuous improvement in key areas specific to divisions and teams. Staff described how this enabled oversight of performance over time and identified areas of concern and improvement that was then shared with staff in divisional newsletters. For example, during our inspection of medical care we identified issues relating to a medicine product. This was flagged during inspection and escalated through the divisional quality and safety meeting and included in the newsletter to staff.

The trust’s board papers, and our observations of the trust’s board meeting demonstrated the board received information related to its core business. Feedback from partners we received, commended the trust on its comprehensive data reporting systems which were shared regularly and easily understood.

Risk Management

The trust had effective arrangements for identifying, recording and managing risks, issues and mitigating actions. Emerging risks were escalated through to trust board by the relevant site executive director or portfolio holder. Data was extracted from the trust’s risk management and information systems and underpinned some of the overall statistical process control reporting. The trust had aligned all of the services provided across the sites to one of the hospital management boards for lead oversight. Standardised hospital management board meetings took place to ensure there was oversight of site-based risks and issues. Risks and issues relating to the Group were also reported into the board via the LUFHT Improvement Plan Portfolio Board. External review of the risk management processes at the trust in December 2024 reported there was a strong system of internal control which was effectively designed to meet the system objectives, and controls were consistently applied in all the areas reviewed.

Staff had access to risk registers and issues logs at team, division and hospital site levels and were able to escalate concerns as needed. The trust had undertaken work to streamline risk management processes and ensure all staff could report and escalate risks through a single system. Staff compliance with mandatory risk management training was at 97%. All leaders and board members had also undertaken additional training in the trust’s risk and assurance model to use the systems effectively.

The trust’s board assurance framework had identified the most significant strategic risks faced by the trust to the delivery of its strategic objectives and improvement plan. The top three risks related to the trust’s elective activity plans, urgent and emergency care provision and financial sustainability. Recorded risks were aligned with what leaders told us were on their ‘worry list’. These were consistently highlighted by leaders and staff as the top risks faced by the trust, particularly urgent and emergency care provision and the impact of long lengths of stay had on patients and ability to care for others. Leaders noted risk scores over time since 2023 had remained static for urgent and emergency care and the financial risk had increased. Mitigating actions for risks were updated where there were changes to report and leaders told us would be updated prior to the implementation of the trust’s 2025/26 strategy.

There were currently four significant risks managed by Corporate Services and presented to the trust board in November 2024. These related to the number of patients with overdue follow-up appointments, delivery of the 65-week elective waiting time target, failure to develop and deliver a cost improvement programme and an inability to achieve a financial balance. We saw that risks were reviewed and ratings changed over time. For example, the 65-week elective waiting time target was escalated from a score of 11 to 12 in July 2024 to reflect the increased number of patients waiting for treatment longer than 65 weeks. In November 2024, a total of 179 patients were reported as waiting over 65 weeks for treatment, three of which were waiting over 78 weeks. A trajectory tool had been developed to support services in projecting performance trajectories and the resources required to offer more timely treatment. Leaders could describe the patient’s individual circumstances that led to a wait of over 78 weeks.

Information governance systems were in place including confidentiality of patient records. The trust had completed the Data Protection Security Toolkit assessment. An independent team had audited it, and the trust acted where needed. There were processes to ensure the integrity and confidentiality of data, records and data management systems. The board received an ‘Annual Information Governance Board Report’. There were 333 information governance incidents during 2023/24 which comprised 325 information governance incidents and 8 cyber related incidents. The trust had seen a reduction in the number of cyber related incidents from the previous year and a comparable number of information governance incidents reported. The trust declared full compliance with the 2023/24 Data Security and Protection Toolkit.

Staff and leaders were open and transparent, and collaborated with all relevant external stakeholders and agencies. Leaders provided examples of how the trust worked in partnership with other organisations both within the local system, the North-West and nationally. The trust chaired the urgent and emergency care recovery programme working with the Local Authority and a local NHS trust providing community services to improve access to unplanned care and treatment and improve discharge of patients from hospital. The trust contributed to the integrated care strategy working with two local trusts aimed to develop the care landscape at neighbourhood, city and district level.

As part of the group model between LUHFT and Liverpool Women's Hospital NHS Foundation Trust the trust's chief executive and chair held joint posts across both trusts.

Staff and leaders engaged with people, communities and partners to share learning with each other that resulted in continuous improvements to the services. Leaders used these networks to identify new or innovative ideas that could lead to better outcomes for people. In our survey of partners in stakeholder engagement events, we received positive feedback in relation to this quality statement. We received positive comments from partners about the trust's approach to partnerships and the communities. All described the trust as an active partner within the local system and partners gave us examples of how the trust had supported system working.

The trust signed up to the Cheshire and Merseyside Anchor Institute Framework, which committed the trust as one of the largest employers in the regions to drive forward sustainable values and the better the lives of the local communities. Working alongside partner institutions, to also support and improve local social and economic conditions.

The trust's existing vision was based on working together with partners and communities to support communities to live healthier, happier, fairer lives. Part of the group model strategy for the Liverpool population required a partnership approach to three care models which were inter-related:

• Streamlining adult acute and specialist care pathways



• Faster diagnosis and treatment to return to the community and proactive contribution to community provided preventative care.



• Integrated care partnership

It identified that some of the existing resources would need to be refocused to neighbourhoods, primary and social care. Leaders explained that further work in this area would be included as part of the Group strategy.

The trust had a three-year plan for improving population health and reducing health inequalities which linked into the board assurance framework. To provide leadership in this area, the trust had employed a consultant in public health medicine who was supported by a senior public health registrar and a health inequalities and anchor programme lead. The plan encompassed three tiers of activity; embedding prevention, embedding equity and fulfilling the trust's role as an anchor institution. The plan was at the beginning of its phase 2, "Consolidate and Develop", with the intention to co-produce a full Prevention and Health Inequalities Strategic Plan for the University Hospitals of Liverpool Group. Analysis of the patient population provided greater insight into the health and care needs of the local community, including the effects of poverty. Inclusion of health equity data was to be used as part of performance reporting.

Work was underway reviewing information available to patients across services and signage to become a health literate organisation and ensure information for patients, families and carers was written in an accessible and understandable manner.

Leaders were undertaking training in equity impact assessments so any potential changes to services could be mapped out using the Core20PLUS5 framework."Core20" represents the population living in the most deprived quintile identified by the Index of Multiple Deprivation (IMD). Nationally, this represents 20% of the population, but for LUHFT's catchment area that includes 57% of residents living in the Trust's catchment area. 'PLUS' represents population groups who are at risk of social exclusion, such as inclusion health groups, and other groups sharing protected characteristics - this may include people experiencing homelessness, people with learning disabilities and people who may have language/communication barriers. An example of service change to reduce inequalities included the development of an outreach team of doctors and nurses, from 5 clinical specialities, working 5 days a week at the drug and alcohol charities, providing health checks and point of care testing and treatment for people with drug and alcohol addictions in Liverpool.

The trust had a process to respond to complaints from people using services and those who had accessed services. We reviewed five complaints and found the trust had acted fully in accordance with the complaints process and had provided a detailed compassionate response to concerns raised with an apology given where appropriate. Learning from complaints was thematically shared across the trust.

The trust's annual complaints 2023/24 report identified themes, trends and learning from complaints. There had been an annual decrease in the number of closer look complaints, (previously referred to as a formal complaint) 318 reported for the period 2023-24 and 410 for the period 2022-23. There was also a reduction in the number of concerns recorded as being addressed at source. The top themes identified, which accounted for 71% of complaints, related to communication, an issue with an appointment, and concern about patient care. Two complaints were raised with the Parliamentary and Health Service Ombudsman during the 2023-24 period.

Service level agreements were in place for the provision of psychiatric liaison services from partner organisations. The trust met with the partner organisations regularly with standardised agendas which included learning from incidents. Metrics were produced for an oversight of capacity and performance.

The trust received 512 responses to the adult inpatient survey and scored about the same compared to other trusts for overall experience, treated with respect and dignity, kindness and compassion, and care and treatment categories. Areas highlighted that were somewhat worse than expected were waiting to get a bed on a ward, being able to take own medication when needed and being given enough information on the rsks and benefits of being on a virtual ward. The trust scored better than expected for patients reporting less disturbances at night due to noise and improved sleep quality.

The trust's governors told us they felt supported to undertake their roles and represented local communities. Governors received induction and training for their roles and worked closely with the non-executive directors and the Chair. Governors undertook visits to services across the trust to meet with staff and patients; reports were completed afterwards to share experience with staff and the board. Governors were involved with the trust's engagement strategy and supported external events in the local community representing the trust.

Feedback from partners was positive in relation to this quality statement. Healthwatch could describe how the trust engaged with them and patients with lived experience to improve services. Partners described the trust understanding their duty to collaboratively work with other services so services worked seamlessly for people who used them and worked there.

Staff and leaders had a good understanding of how to make improvements happen using a consistent approach and outcomes and impact were measured. People using services were involved in improvement and innovation. The trust held patient and public engagement events, engaged with Healthwatch, linked in with local communities and charities and held patient support groups. The LUHFT Engagement Partner Programme provided the opportunity for patients, carers, community and charity representatives to register their interest to share their lived experience and views to represent their communities. At the end of September 2024, 100 engagement partners had signed up, including 10 third sector organisations. Fifteen engagement events had taken place across a 6-month period; some of which included feedback and comments on the trust’s Antiracism statement and action plan; “All eyes on you” event at St Pauls eye hospital in collaboration with University of Liverpool; participation in the review of digital improvement pathway project and feedback relating to trust websites and patient focus groups. Specific engagement with local charities included engagement with young carers groups, people living with dementia, people with learning disabilities, religious and cultural groups and people with impaired hearing. Healthwatch held a listening events for the trust with focus on reablement, supported the implementation of Martha’s Rule (allows patients, families, and carers to request a rapid review from a critical care outreach team if they have concerns about a patient's deteriorating condition) and raised staff awareness of gender diverse and non-binary people.

Leaders told us that patient support groups tended to be facilitated and hosted locally and central records of activities were not kept. As a result, the trust had set up a toolkit for staff to facilitate such groups and implemented a central record to capture activity. There were over 50 patient support groups registered at the trust which included a Parkinson’s diagnosis café, endoscopy focus group and a learning disability cancer support group.

Processes were in place to ensure staff accessed professional development and support to enhance patient care provision. Supervision and appraisal rates were above target at all sites. Medical appraisal rates for varied between 82% and 100%. Mandatory training compliance were above target at all sites apart from the New Royal University Hospital which was slightly under 90% at 89.63%. Lower achievement was seen in areas such as paediatric life support and resuscitation sessions which were held face to face and the trust did not routinely treat children. Further sessions had been planned to increase compliance.

In the 2023 NHS Staff Survey, the trust scored 5.21 for the people promise element ‘We are always learning’ which was below the national average, but an increase from 4.38 in 2022. For the question “In the last 12 months, have you had an appraisal, annual review, development review, or Knowledge and Skills Framework (KSF) development review?”, 83.3% of respondents answered “Yes”, which is comparable to the average of 83.1%.

There were processes to ensure that learning happened when things went wrong, and from examples of good practice. Leaders encouraged reflection and collective problem-solving. The trust had systems to learn from deaths, inquests, patient safety incidents and alerts from national bodies. Learning from deaths was reported to the site quality standards committees through to the board. The trust undertook a retrospective analysis of previously reported incidents and additional complimentary data sets such as claims, complaints, and cultural surveys. Patient representatives, members of the public and commissioners had the opportunity to review incident types and recommend the focus for future investigations as part of the incident framework implementation group.

The patient safety incident response plan outlined the learning for each patient safety incident type required response and the anticipated improvement route. From November 2023 to November 2024, the trust commissioned a total of 416 individual learning responses of which 5 patient safety incident investigations were commissioned. Investigatory reports were shared with the Integrated Care Board within the required timeframes. Individual learning responses supported a reduction in certain types of incident reoccurring such as a reduction in the rate of falls and pressure ulcers across the trust. Improvements were also seen in the timely completion and recording of patient observations achieving 90%, and completion of risk assessments linked to blood clot formation at 95%. The trust could demonstrate where patients and staff contributed to the investigatory processes and feedback was acted upon.

Leaders expressed confidence in the trust’s initial incident review processes which ensured immediate learning from incidents was identified and shared. An external audit agency undertook a review of the trust’s patient safety incident framework in November 2024 and found it to be compliant with standards.

The transformational delivery unit was established in 2023 to embed ward to board improvement across the organisation. This included developing a strategic approach and roadmap, managing delivery using a dedicated programme and quality improvement professionals, focusing on outcomes through performance dashboards and statistical process control. It was enabled by a communication and engagement plan aligned to the overall trust improvement plan.

Following the last CQC inspection the trust developed and implemented the fundamentals of care programme, deteriorating patient collaborative, dementia and delirium screening, clinical reliability groups and valuing patients’ time improvement. These were underpinned by a framework through which patient safety improvements could be implemented. The fundamentals of care programme focused on falls, pressure ulcers and nutrition and hydration. As a result, a cohort of wards were selected and staff trained in quality improvement methodology with support from the trust’s quality improvement team, incident reporting systems were refined, statistical data was made available to staff and change bundles were available to share across sites to share learning. As a result, there was a reduction in the number of falls sustained from an average of 12 per week to 8.2, an increase in completion of nutrition and hydration to just under 95% and a reduction in the number of pressure ulcers. Throughout our inspections across urgent and emergency care and medical care we saw examples of local quality improvement initiatives to improve care to patients including decaffeinated drinks to reduce the number of falls and training to support staff to prevent deconditioning in patients attending hospital. Staff were trained in quality improvement methodology and had access to local quality improvement coaches to support them to develop their improvement ideas. Leaders could describe specific quality improvement initiatives in frontline services including initiatives to improve dementia and delirium screening and facilitating timely discharge.

Quality improvement initiatives and performance overtime were reported to the board via the improvement plan portfolio board. The improvement plan dashboard detailed progress with quality improvement projects in the trust’s frontline services and assured the board of the effectiveness of the delivery of the trust’s improvement plan.

The trust had an internal audit plan, an annual audit cycle and had completed 121 clinical audits in the past 12 months covering areas including review of discharge summaries, adherence to infection prevention and control and NICE guidelines.

The trust had received several accreditations from external partners including improving the quality of liver services and meeting best practice for endoscopy standards. The stroke emergency assessment unit at University Hospital Aintree was awarded an NHS Parliamentary Award for excellence in urgent and emergency care.

The service had strong external relationships which supported improvement and innovation. Staff and leaders engaged with external work, including research, and embedded evidence-based practice in the organisation.

The trust had a research department, a research strategy and the Royal Liverpool and Aintree hospital sites were founding members of Liverpool Health Partners which was now hosted by the trust. The Royal Liverpool, and subsequently LUHFT, hosted the National Institute for Health and Care Research (NIHR) North-West Coast Clinical Research Network (X-Y). The trust also hosted the NIHR Liverpool Clinical Research Facility – only one of two NHS accredited early phase clinical trial facilities in the UK; the newly awarded NIHR Cheshire and Merseyside Commercial Research Delivery Centre and the host-designate of the NIHR Applied Research Collaboration 2, should renewal funding be awarded.

The trust collaborated closely with the University of Liverpool, Edge Hill University, Liverpool John Moore’s University, the University of Chester and other local and regional NHS organisations. A research and innovation performance and delivery report was produced annually. The most recent report included 304 open studies, 145 studies being followed up, 96 studies in the set-up phase run by 220 principal investigators and 60 chief investigators with 5,513 study participants across 29 specialities. Studies included the largest head and neck research study in the world.

Partners were positive about the trust’s approach to learning, improvement and innovation. Partners told us the trust had a learning culture and were aware of the quality improvement initiatives underway. In our survey of partners in stakeholder engagement events, we received positive feedback in relation to this quality statement.

The trust had a Sustainable Development Plan 2024/27 which was approved by the board in January 2025 and replaced the Sustainable Strategy 2021/2025. The Sustainable Development plan set out the actions to reduce the trust’s environmental impact and to meet trust and national carbon targets. Leaders recognised the direct and indirect impacts climate change would have on peoples’ health and well-being and were committed to improve public health. The plan was monitored at site level and then reported to board through hospital management boards. The trust’s estates varied from a newer purpose-built building to older buildings built at the turn of this century. Thirty-four estates risks had been identified that fed into the board assurance risk framework and included the substantive removal of reinforced autoclaved aerated concrete (RAAC) at one of the sites.

The Sustainable Development plan identified the international, national, local and internal drivers and how it would link in to deliver the Government’s net zero plan. The plan included 14 ‘principal areas of focus’ in areas including travel and transport, estates and facilities, supply chain and procurement and climate adaption. Each area of focus was mapped to sustainable development goals to monitor achievements.

The trust promoted the ‘gloves off’ campaign which encouraged staff only to wear gloves when clinically indicated linking into the environmental goal of reducing the number of gloves used and improve hand hygiene compliance. There were higher numbers of some infections reported at across the trust which were spread by direct contact. Improving hand hygiene without the use of gloves was part of the trust’s internal plan of action to reduce the spread of infections. In depth review of a sample of patients who experienced an infection had been undertaken to contribute to further external reviews and identify systemic learning.

A new medicines optimisation strategy was being implemented along with a Medicines Safety Improvement Programme linked to the trust’s and national priorities. Medicines optimisation aimed to improve medicinal safety, adherence, and reduce waste, ultimately leading to better health outcomes for patients and value for money. Pharmacy staff were integrated across hospital sites and at a ward level, supported by the senior leadership. The pharmacy service worked to standardised policies, procedures and adhered to medicines optimisation benefits across all hospital sites.

There were clear lines of communication from the Chief Pharmacist to the executive board and clear pathways for both non-clinical and clinical decisions to be made. The Chief Pharmacist was also the Trust’s Accountable Officer (AO) for Controlled Drugs. The Medicines Safety Officer and associated team members had a good oversight of the medicines-related areas which required improvement across the hospital sites. Evidence was presented demonstrating improvements being made and specific projects underway. One successful example was the work done to improve the timely administration of ‘time-critical’ medicines across the hospital sites

The pharmacy team worked closely with other partners in the integrated care system and were involved with Cheshire and Merseyside sodium valproate safety work. This included standardising alert warnings and the roles and responsibilities of all staff across primary and secondary care relating to this drug.

An innovative pharmacy ‘portal’ system was developed within the pharmacy team to enable pharmacy professionals to identify and prioritise higher-risk patients when conducting their ward-based activities. This system was constantly being modified and enhanced.

The trust had introduced sustainability champions who led on internal engagement on environmental sustainability and 100 champions had come forward with ideas for consideration.

Leaders were aware of the trust’s impact on environmental sustainability. They were able to provide examples of where the trust had made changes to reduce the trust’s carbon footprint, which had been delivered as a result of the Sustainable Development Plan. These examples included an investment in installing of solar panels across the sites, reduction of single use plastics, and changing the types of inhalers prescribed.

The trust’s chief finance officer was the board level lead for the trust’s Sustainable Development Plan.

Partners gave us examples of the personal commitment demonstrated by the trust’s leaders to environmental sustainability. Partners were aware the trust had a sustainable development plan.