Nottinghamshire Healthcare 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 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Not all board members had the shared vision, strategy or just culture to consistently drive forward effective change and strategic goals of the trust. We were not assured that the board always worked in a cohesive and collaborative way to achieve its strategic goals. There was a disconnect and conflict between quality and finance, and governance responsibilities. Not all non-executive directors carried out their roles and responsibilities with sufficient, or robust challenge to aid the board to remain focused on strategic delivery. The trust board had, at the time of our assessment, refreshed the trust’s financial improvement for recovery whilst improving patient outcomes. Trust leaders did not always talk about patient experience in line with their strategic goals.

The trust vision, combined with the trust values described how it planned delivery of care to patients, through overarching values of trust, honesty, respect, compassion and teamwork. The trust had a strategy called ‘Making a Difference 2022-2027’, published in early 2022. The values were mostly well-established across the trust. We heard mixed views about the trust values in action. Some focus groups reported negatively about how staff worked to the trust values every day, and some of our assessments of services showed positive examples of values in action. Some senior leaders were inspirational in their leadership and role modelling of behaviours, but some senior leaders remained in a grip and control mindset within their teams.

A trust presentation during our assessment described a ‘North Star’ strategic aim “to make Notts Healthcare a great place to work: empowering our staff to deliver exceptional patient care.” However, during our interviews, executive and senior leaders did not articulate the North Star aim and it was not common in their language or conversation.

The trust provided examples of how partners had been engaged in the development of the trust’s strategy in 2022. Partners, including those with established relationships with the trust, gave feedback that they had been involved in the development of the trust’s strategy. At the time, partners were satisfied that the trust’s strategic objectives were aligned to the objectives and priorities within the local system and felt the trust would be able to deliver against the strategic objectives.

In March 2024, the trust embarked on an organisational change programme. This consisted of leadership changes, lines of accountability reviewed and reorganised. Clinical leadership was strengthened within each care group. The executive team acknowledged this had been a difficult process and was hugely unsettling for staff within the organisation. Staff reported to us, mixed reflections of the process. During our focus groups and during our assessment of services, some staff felt ‘done to’ yet others felt they had been consulted and involved in service redesign. However, overwhelmingly, staff at most levels of the organisation, told us there was an impact to staff with the speed at which decisions were communicated from the board. The pace at which messages and rationales were shared was not fully understood by all staff.

We saw how the trust reorganisation had realigned services into 3 care groups with a revised accountability framework. There was energy and focus amongst care group leadership for the new framework. The accountability framework provided better and improved consistency in reporting to board, although the board recognised this was still to be implemented. It was to be presented to board for approval after our assessment. We reviewed the public board papers of September 2025, and found a paper presented to board for a ‘terms of reference review’ for trust committees, approve establishment of the Mental health legislation committee and a review of the Charitable Funds Committee. There was no paper presented to approve the accountability framework.

The 2022 strategy had four strategic areas of focus (objectives) for the next five years; our people, our care, our performance and working together. An annual operational plan supported the strategic objectives. The trust had planned to set annual priorities through their annual planning cycle to drive the practical actions within their 6 ‘enabling plans’. The trust had 6 ‘enabling plans’; a digital strategy, a workforce plan, an estates strategy, food and nutrition strategy (2021-2024) a green plan and a financial plan. Together, this formed the trust’s strategic framework. A board assurance framework underpinned the strategic risks, risk appetite and assurance to deliver the vision and strategy.

We were not assured that the entire board were aligned to the approach described above. Several different executives, associate directors and other senior managers we spoke with, told us they were working towards other strategies such as a Freedom to Speak Up strategy, a People Plan, but were mostly driven and directed by an Integrated Improvement Plan (IIP), or as named by the trust “Our Big Plan: 2025-2026”. The Integrated Improvement Plan was formulated by the board, in December 2024, and refreshed in April 2025, in collaboration with service users and carers from across the organisation. The board had identified a need to simplify multiple requests on the trust within complex health and social care system pressures. Between 01 June 2024 and 23 May 2025, 61 ‘Big Conversations’ took place across the trust, involving 1478 staff. These events held conversations about how the organisation and staff can make improvements for those who use services. Executives heard during these events that key areas for improvement were caring for neuro divergent people, patient safety, staffing, communication and how to get support in a crisis. Strengthening staff morale and having better care coordination were identified at the events as important factors. The board were open to holding open conversations in order that the organisation met needs of individuals. The board firmly believed that involvement of staff, service users and carers in decision making was crucial to improving services. However, during our interviews at this assessment, the patient voice did not often feature in conversations and came second to other key matters in the forefront of senior leaders’ priorities.

Despite feedback that these events reflected shared passion and a desire of staff to work together to do things differently, the ‘North Star’ strategic aim (Making Notts Healthcare a great place to work: empowering our staff to deliver exceptional care’), was yet to be finalised at the time of our assessment. Of the 7 board executives, 5 had been given responsibility for delivery of the IIP. The IIP had a focus on immediate actions for 2024-2025, a refreshed version for 2024 – 2025 with a focus to transition out of NOF4 (level 4, NHS oversight framework) and to meet regulatory requirements. The 2026 forward plan was yet to be decided, but the board had initial plans that this would include reduced scrutiny and oversight form the system which would allow greater control over their areas of focus.

Not all leaders consistently demonstrated their commitment to compassionate and inclusive leadership through timely and targeted actions. Whilst they described their positivity towards promoting a positive trust culture, executive leaders had not consistently delivered actions to prioritise equality and diversity throughout the organisation. However, in services, most leaders understood their role in leading by example, modelling positive and inclusive and compassionate behaviours.

The trust’s board comprised of 7 executive directors and 8 non-executive directors, including the trust’s chair. A council of 27 governors was also in place. The executive team held a wide range of individual and extensive portfolios covering areas including quality, effectiveness, risk management, finance, procurement and organisational development. The board was made up of executive directors and NEDs who had been working for the organisation for many years with significant organisational history, and some who were relatively new to post, with over 50% of the executive board new to the trust having joined in or after 2022. There was a board development programme in place and development sessions for board members took place regularly there had recently been a session for autism training, a deep dive into the board assurance framework and understanding regulation. Board members told us new appointments to positions on the board were positive and brought new energy to the organisation. The post of chair was being actively recruited to at the time of our assessment; this was due to the current post holder’s tenure coming to an end. The recruitment was led by key stakeholders within the health and care wider system.

The non-executive directors (NEDs) we spoke with demonstrated their understanding of the complex leadership issues facing the trust. Board papers, minutes of trust committees and interviews showed a mixed view that the NEDs had the appetite to challenge the executive group and support the drive for change at pace. We saw that work was needed to further develop the executive team as a whole. Some non-executive directors did not consistently discharge their responsibility of robust challenge on strategic oversight, and at times accepted reassurance rather than assurance on key matters. Two non-executive director positions had been recently appointed to and the NED group felt this had brought about positive change and energy to collaborative working. Board development sessions took place regularly. The sessions were used to review key issues, governance frameworks and as learning and development opportunities. NEDs felt they had good relationships with executive directors and were supported in their role within the trust. Opportunities to push forward with strategic objectives were not always taken in a timely way, for example offender healthcare, closer alignment of community health services and estates issues within the organisation.

The trust had a Council of Governors which consisted of 27 Governors, comprising 14 elected public governors, 8 elected staff Governors and 5 appointed partner Governors. The role of a Governor is to represent their constituents in this case patients and staff and to hold the NEDs to account. The Council of Governors met on a quarterly basis, and meetings were open for members of the public and staff to observe. Some governor positions had been vacant for some time, and the length of service by governors ranged from 1 month to several (10) years. They discharged their role of governance oversight, check and challenge with purpose, especially with the NEDs, and told us they saw the trust was “gradually making improvements”. Both Governors and the trust board reflected that there was more to be done to ensure effective use of the Governors roles to build better engagement and to support meaningful change aligned to the priorities set out in the Trust strategy.

Leaders understood the need to have an embedded, positive culture amongst the staff in the organisation. However, whilst this was acknowledged, we were not assured all executive and senior leaders could clearly articulate a consistent vision of how the board would create and embed an open, valued, inclusive and just culture throughout all areas of the organisation. We saw the boards’ priority was to deliver the IIP which took focus away from embedding a positive, listening and compassionate culture at all levels of the organisation through their published strategies and objectives. We found board triumvirate working was not collaborating effectively in leading this work. Phrases such as just culture, compassionate leadership and a no blame culture were overlapping concepts used throughout the senior leadership team.

In March 2025, the board meeting minutes provided an overview of the staff survey results 2024, and shared plans to address the findings. A paper presented to board acknowledged significant work was required to improve colleague experience at the trust. Five high impact actions were provided which included further roll out of a number of leadership programmes, improve communications, provide opportunities for staff to meet directly with executives (Big Conversations) and learn from others. In July 2025, at the board of directors meeting, a commitment was made to assure the board that plans for 2025 included but were not limited to; the executive team ‘will lead from the top’, demonstrate the importance of completing the next staff survey, improve communications about the survey, and make the survey more accessible for staff. The board of directors received assurance that the trust would only improve their staff survey results by ‘ensuring all leaders were responsible for the survey’, ‘see its value’ and were able to ‘bust myths around confidentiality and lack of action’. Whilst the paper in March 2025 suggested the results of the survey allowed the board to agree their response and work quickly on the receipt of the results, reference was again made to the IIP which would help to bring about change in these areas. This paper had already been considered previously by the executive leadership team in January 2025, private board of January 2025 and the people committee in February 2025. The IIP had a defined aim (‘Equipping our leaders to make the trust a great place to work’) and objectives to improve organisational culture through leadership development. However, key project leads both clinical and operational were still to be identified.

We saw subsequent papers that followed, presented to committees and board, continued to seek assurance and commit to action to deliver the people plan within 4 pillars through the IIP, rather than report on concrete actions that had been achieved and had had impact on an improved culture.

Negative scores within the staff survey 2024, showed 7 ‘people promise’ elements and 2 themes of ‘staff engagement’ and ‘morale’ with a statistically negative change from the previous year. Staff continued to raise concerns in feedback that support negative culture concerns in the trust. In May 2025 the board noted risks faced by the freedom to speak up guardians (FTSU) but also the risks to ‘people and culture’ of the organisation were linked to an increase in staff sickness, decreased staff retention, poor leadership, the risk that a quality and safety culture did not exist and the impact of finance of tribunals and litigation cases. It was recorded that efforts such as leadership courses, Culture Trailblazers and Team Engagement Development tool (TED) were targeted mitigations to improve culture and minimise the risks. Despite the risk highlighted to speaking up, our interviews with senior leaders, executives and directions of services, demonstrated they were aware of the capability and capacity around FTSU but the governance oversight and ways to address the risk was not clear.

We were not assured that senior leaders had a joined-up approach to mitigate the risk to organisational culture and engagement. In a meeting of the people committee in August 2025, the board assurance framework was reviewed, in particular the ‘people risk’. This risk was documented as ‘our colleagues experience at work is poor; leading to poor engagement, higher levels of absence, higher levels of turnover and colleagues who are less likely to recommend us as a place to work or receive care’.

The cause for this risk was directly attributed to staff. Language used to describe the cause of the risk blamed staff (for ‘lack of experience, competence, confidence, emotional intelligence or work pressures’ and leaders may not act in line with our behaviours’ ‘leading to reduction in employee engagement, morale….which can all impact on the quality of patient experience and care we can provide’) as a cause of a strategic threat that would prevent high quality and safe care delivery. Board members had not realised how the implications the language used could impact staff morale. Moreover, it demonstrated a lack of recognition that by embedding a just and compassionate culture, leading by example at board level, could empower staff at all levels of the organisation to perform at their best and lead to an embedded inclusive and positive culture throughout.

The trust had rated the people risk as an open risk level and high appetite which meant the trust was willing to consider all options to mitigate this risk and choose the one most likely to result in successful delivery of reward. The board had agreed the risk had limited assurance from the people committee (August 2025). The plans to improve control of this risk were to implement leadership programmes, improved engagement via communications; develop the Pro-equity plan, use of the Freedom to Speak Up service, appraisals for leaders and use of health and wellbeing services. In order to control the risk of staff engagement, the board had identified they needed to devolve decision making back to frontline managers, set a clear benchmark of staffing for inpatient areas, deliver ‘Valuing Medical Leadership’ programme and provide learning and development opportunities for staff. Whilst those we spoke with were able to articulate the risk, they were not clear on which risk controls were a top priority, and the board were largely focused on leadership programmes for the top slice of leaders in the trust rather than a trust wide approach of a cultural change programme.

Many senior leaders, heads of function and board were positive about the compassionate leadership of the chief executive and the chief nurse. They were described as demonstrating trust values and their work was pivotal in improving culture, leadership development and a safety culture in the trust. We saw associate directors, strategic leads of departments or care groups positively role model a shared vision of how a positive and just culture impacted better care delivery for patients. We saw some areas of the trust where leaders were compassionate. Staff survey results showed 83% of staff felt their role made a difference to service users, and 81% of staff enjoyed working with staff in their team. We saw this translated into motivated and caring, compassionate staff in most of our service level assessments.

We saw posters that described the trust’s Pro-equity approach. Limited numbers of senior leaders described the Pro-equity approach the trust wished to embed throughout the organisation. Whilst the reason to deliver this approach was positive and required, it was fundamentally unclear the board had fully understood and had a grip of the complexity of the current quality diversity and inclusion (EDI) position, and how data could be used to improve the experience of staff in the organisation. The executive directors did not have clear expectations and measurable strategic objectives outlined through a robust and documented annual appraisal process.

The knowledge of some of the executive team on this issue was not clear and some of the team were unable to speak actively to the data the trust held on EDI. The people committee heard a staff members story at their meeting in August 2025, where racial discrimination and poor practice from leaders was experienced. Whilst learning had been identified from this experience, the committee recorded they still needed to understand how trust data was triangulated and queried how such cultures were being identified and addressed. The meeting lacked decisions on how to share learning, how data was triangulated and how the board made decisions to actively address culture change. Leaders did not describe to us the trust’s approach that EDI was the ‘golden thread’ in the IIP as EDI did not feature within the IIP. Initiatives such as further training, Allyship and DI guardians would support the Pro-equity approach. Improved engagement and involvement with EDI networks, co-production and system working alongside governance steering groups and committees would also support the approach. Leaders did not articulate the details of the Pro-equity approach and there was not a joined-up approach amongst the leadership team to prioritise and promote this vision.

The trust had made significant efforts to develop ways in which staff were enabled to raise concerns to drive improvement and feel heard by senior leaders without fear of reprisal. Investment had been made to foster a culture of learning and take action to respond to concerns, but this was not consistent across all services in the organisation.

The trust had a Freedom To Speak Up Guardian (FTSUG) and a deputy, who had strong links with an executive lead (within the people and partnerships portfolio) on the board and other board members, and had regular supervision. There were strong governance arrangements for reporting from ward to board, via committees, required reporting and twice a year audits. Whilst the FTSU Guardian did not have a direct report into the CEO, we saw the CEO wanted the trust to be ‘a loud organisation’ where leaders and staff were ‘hands on’ to speak out and improve service quality and safety. There was a direct report for the Guardian to an executive director and a reporting process to executive board. The CEO offered an ‘open door’ policy for the Guardian. The trust had 104 staff members trained as FTSU champions who promoted speaking up across the trust. Champion training was in place and quarterly development sessions were held. All staff received FTSU training on induction, mandatory training in ‘Speak up, Listen up and Follow up’ and bespoke training was delivered by champions. Visibility of champions and the messaging of FTSU was strong within services. We saw plans where continued development of the Guardian role and the role of champions was well underway. The Guardian had effective links with networks in the integrated care system (ICS) which met bimonthly for support, networking and shared good practice.

The 2024 staff survey results showed “We all have a voice that counts” element had declined from the 2023 survey results and was a lower score compared to other organisations. The people committee stated the results presented a very concerning position for the trust and reflected to board the need to respond to the results robustly and consistently during 2025 was a top priority for the trust. Actions taken by the trust included ‘Big Conversations’, leadership programmes, ‘Creating Compassionate Cultures’ programme, organisational change programme and making listening and follow up actions a key priority and responsibility for managers across the organisations.

We spoke with associate directors, leads of departments and senior leaders in services who, on the whole, role-modelled good speaking up behaviours. They listened to staff feedback and concerns, they demonstrated candour and empathy when things went wrong, and they celebrated speaking up.

The evidence reviewed demonstrated a culture in which staff felt more able over the last 12 months to raise concerns, report incidents and suggest improvements. Communications such as the “You shared, We listened Together we…” brand, publicised changes made in response to staff feedback. The trusts’ guardian had been involved in national events, reaching out to underrepresented groups through proactive work within services, team meetings, networks and team development days. A ‘Your voice counts’ initiative was launched in early 2025 to share learning from speak up concerns, to close the feedback loop.

The trust had a FTSU strategy (2023-2027) which had 3 key priorities. An improvement strategy workplan sat alongside the strategy which tracked progress of the strategic outcomes. It was positive to see that 35 deliverables had been recorded with positive impacts of improvement found and evidence provided and recorded as embedded into practice and signed off by the appropriate forum. It was clear that the work carried out, driven by the speak up team across the trust had a positive impact on speaking up. However, we could not be assured the board had effective or regular oversight of this workplan. The workplan had 42 deliverables all of which had start dates of April 2023, September 2023, February 2024 or April 2024 and all had completion target dates of 31 March 2027. Seven activities were recorded as progressing to time and showed evidence of progress but the commentary for these activities had been updated in May 2024, June 2024 or not at all. For example, the digital system for anonymous concerns was recorded as “hopefully functional by quarter 3 2025/26; leaders being responsive and timely in addressing concerns was recorded as “room for improvement”.

The foreword of the FTSU strategy was authored by a NED who no longer worked at the trust, and we observed the FTSU improvement workplan had no current position to update or refresh the strategy with a new sponsor from the executive team.

There was a strong link between the FTSU role and improving patient safety within the trust and the Guardian had a role in serious incident review meetings which allowed for the escalation of concerns. The trust leadership team told us they felt positive about the increase in staff speaking up. A total of 567 FTSU cases were raised to the trust between 01 April 2024 and 31 March 2025. This was higher than all other similarly sized trusts in the Midlands region and data showed the trusts’ mental health care group had the highest number of speaking up cases. The majority of cases were raised by clinical staff. There was a significant increase in speak up cases from medical staff compared to the previous year. Themes and trends included patient safety concerns (65 cases), staffing issues and staff wellbeing (130) bullying and harassment (68) and attitudes and behaviours of others (179). 282 of the cases pointed towards improvement in culture to speak up. 2% of all cases were raised anonymously (third lowest total across trusts in the Midlands), which indicated that staff felt comfortable to raise concerns to the Guardian during this period. The trust board received assurance during meetings where FTSU data was reviewed. Data showed 80% of those who gave feedback said they would speak up again. The board had been sighted on risks to the continued improvement of FTSU culture. The board had noted in May 2025, that risks to the FTSU agenda was capacity to change the workload within the team, case backlog and a lack of a digital recording system and untimely resolution of cases. We heard that there was no process within the trust to raise concerns anonymously (except to create an anonymous email address) and this was to be addressed by quarter 3 in 2025/26. Some staff in some services felt fearful of raising concerns, but this was not consistent across the trust. A small number of staff in some areas of the trust had negative experiences of speaking up, stating they had suffered disadvantageous and or demeaning treatment because of speaking up (4 cases). Continued success of FTSU in the trust would be determined by continued collaboration between senior leaders in the organisation and the visibility of FTSU, engagement and employee relations improving.

Trust leaders told us they valued diversity in the workforce and promoted an inclusive and fair culture. We saw strategies and documents, policies and processes which made reference to this and the importance of promoting workforce equality. However, the oversight of the board, and actions of the executive team did not always support, align to or drive what was written into strategy and process. We saw there was an infrastructure within the trust to take forward workforce equality and diversity, but other priorities for the organisation overtook the work needed in this area. There was a gap in knowledge and strategic drive of the leadership team, given their ambition to deliver on their people promise.

The trust had designed a ‘Pro-equity culture’ approach which in principle was grounded, and the hope to achieve this was clear. However, the executive team and senior leaders gave mixed messages on how they understood how to use EDI data to maintain grip and focus on the complexity of EDI in the organisation. The knowledge of the executive team to deliver a diverse and equitable workforce seemed limited given the population they served. Executive leaders did not have clear measurable objectives to drive EDI change.

There was a robust governance structure in place where EDI was overseen. Working groups, networks, staff survey results and people issues were agenda items in all care group meetings, the People and Culture Committee and at board where EDI was discussed regularly. Across the trust there were 127 EDI ambassadors. The trust had an executive lead and associate director for EDI, and each care group had a lead for EDI and the responsibility for local action plans sat here. The executive board had a development session on EDI. We saw pockets of positive practice throughout the trust where EDI was actioned, which for example, included an internal equality impact assessment process, and a robust EDI in Employment and Service Delivery Policy. The trust had made significant progress in transgender inclusion and Allyship. Local EDI leads celebrated religious festivals, diversity and cultural events, which staff and patients could be involved in.

Staff networks were strong and active in the trust, with executive leads engaged with 70 members (EMBRACE, LGBTQ+, Disability network and Armed Forces Network). Regular meetings took place with the executive champions, chair and CEO. However, staff told us, during focus groups, those from minority groups had feelings of isolation, fear and felt undervalued. Language used by some staff in the trust meant they did not feel psychologically safe and included within their teams.

Organisational wide events and support mechanisms were in place to promote and champion workforce equality and diversity; For example; ‘Our Big Conversations’ events, patient stories heard bimonthly at board, a wide-reaching wellbeing offer, the trust signed up to the Sexual Safety Charter in April 2024, and a domestic Violence and Abuse Policy in place were examples where the trust had made steps towards improvements in EDI action plans. Twenty diversity and inclusion recruitment guardians had been trained to guide EDI in recruitment of senior and executive leaders. The gender pay gap was an area reviewed by the board; however, the report was brief and did not provide narrative or explanation on the potential drivers to further develop this area.

Whilst operational initiatives, corporate actions, groups and events were positive, the trust leadership team lacked strategic focus and a timely direction of travel to implement fundamental and embedded change in staff culture. For example, the Pro-equity approach was initiated in April 2023, was agreed at public board in September 2024 and the Pro-equity board development session was held in June 2025. However, this was not consistently described by senior leaders at this assessment. An update was then provided to board via the People and Culture Committee on 05 September 2025. Other examples included an ‘Active Bystander’ programme launched in July 2025 (a workplace dignity and respect initiative), reasonable adjustments guide, to be launched summer 2025, and recruitment and selection training launched in Autmn 2024. The Parallel Learning Partnerships programme, established in April 2023, involved 17 pairs of colleagues which saw staff from minority racial backgrounds paired with senior leaders discuss issues of EDI. A 4th cohort was planned to launch in Autumn 2025. These examples demonstrated the trust was committed to improving the EDI agenda in the workforce, but other priorities over the last 18 months to 2 years had significantly halted strategic progress. We have concluded that had such external scrutiny and oversight not been so intense for the trust, then it is likely more progress would have been made.

The response rate to the 2024 staff survey had declined from 2023 (52%) to 46% in 2024. The staff survey 2024 results suggested staff felt increasingly unsupported and unrewarded when compared to previous years. All 7 People Promise elements as well as 2 themes of staff engagement and morale showed a negative change from previous years scores with scores below the national average. “We are recognised and rewarded” and “We are a team” were the lowest score when compared with other comparable trusts. All 5 questions of “We are recognised and rewarded” scored lower than average and deterioration from 2023 results. 2 of the 5 questions had the lowest national score and 2 other questions were 1% away from the lowest national scores. Within the morale theme, staff felt work pressures, as evidenced by feeling unable to manage conflicting demands and that there wasn’t enough staff to do their job properly. Results showed, focus groups told us and some of our service level assessments demonstrated staff did not feel involved in changes that affected their work area and relationships at work could be strained.

We saw that staffing had a significant impact on team and individual morale in service. The trust board were well sighted on the staffing data, but we were not assured the data was consistently accurate and therefore could not always be responded to accurately. For example, the board were sighted on staffing data 2 months in arrears, using performance charts, and integrated performance reports for all staffing metrics, including sickness, fill rates, recruitment, vacancies supervision and appraisals. Some care groups had data for all staff groups, other care groups focused on nursing and medics metrics. Our service level assessments reported on significant staffing challenges in high secure hospitals, forensic and secure in-patient wards, Community Health Services inpatient locations and acute mental health wards of working age adults. In these services there was a direct correlation between staffing issues, (sickness, recruitment and retention), restrictive practices in mental health and where staff reported poor morale and poor wellbeing. When compared to other mental health trusts in the midlands region the trust consistently had the highest sickness rate for all staff groups combined (between March 2024 and 20 June 2025).

Of the questions associated with the “We are compassionate and inclusive” People Promise element, all questions showed a deterioration from 2023 results. The responses showed staff felt unsupported and dismissed by managers. Less than 50% of survey respondents would recommend the trust as an organisation to work for, or to receive care from if their friends or relatives needed treatment, 12% and 10% deteriorations respectively from 2023. When asked whether the people they worked with were kind, polite and respectful to each other the results were very close to the lowest (worst) national score. Some staff in services, reflected indicators of closed cultures in some services, including poor leadership and management skills, training and supervision of staff. In closed cultures, people are more likely to face abuse, avoidable harm and breaches of Human Rights Act 1998 and the equality Act 2010. Some staff told us when they raised concerns it led to reprisals often from senior staff, and while the general culture was described as mixed across the organisation, there were some groups of staff who said relationships between staff were poor and staff reported negative wellbeing. Some focus groups as part of this assessment described a blame culture, ‘tribal’ references made to staff, and words of some leaders were ‘sentiments’ and implementation of EDI was dependent on local interpretation and styles of line managers. Senior leaders were consistent that this was not the culture they were looking to create within the trust.

The trust scored worse than the national average for 4 of the NHS Workforce Race Equality Standard (WRES) of the 9 indicators measured through the 2024 NHS Staff Survey for staff from all other ethnic groups combined, indicating much worse experiences for these staff members when compared nationally. Results showed that BME staff not only experienced harassment and bullying (including patients, other members of staff) and discrimination from their manager/team leader or other colleagues at a higher rate than white employees, but also at a higher rate than the national average. Additionally, BME staff were less inclined to believe that their organisation provided equal opportunities for career progression or promotion compared to white staff at the trust who answered the same question. However, the percentage of BME employees employed at the trust rose to 16% from 18% since 2021/22; BME colleagues who entered the formal disciplinary process compared to white colleagues decreased from 4.5% to 1.2% in 2024/25. In 2024/25 BME staff were more likely to access non-mandatory training and CPD and the percentage of BME staff who believed the trust provided equal opportunities for career progression or promotion increased by 8% from 2021/22 to 48% in 2024/5.

The indicator which measured equality and diversity of board members of BME backgrounds compared to the workforce of the trust indicated a lower result to 2022/23 and remained the same in 2023/24 at 13% of its workforce.

The trust performance showed worsening experiences for staff with disabilities when compared to staff without a disability, for 6 of the 10 Workforce Disability Equality Standards (WDES) from the 2024 NHS Staff Survey, when compared to the previous 2023 NHS Staff Survey, which in 2024/25 indicated worse experiences for staff with long term conditions or illnesses at the trust when compared to staff without a long-term condition of illness. Staff with long-term conditions (LTC) illness consistently reported a worse experience than staff without, across all questions, including higher rates of harassment and bullying (including from patients, managers, and other colleagues). They were also less likely to have reported harassment, bullying or abuse at work, and felt less valued by the organisation compared to staff without a LTC / illness.

The indicator which measured disability within the trust board, compared to workforce of the trust, indicated a decrease of 7% over the last year. (This was due to the workforce with a disability increasing and board members with a disability increasing).

We were not fully assured progress to address the results from the indicators in the survey were pursued with robust purpose by the board. The trust People and Culture Committee presented a paper to board in early September 2025, to outline actions required to address the results of the WRES and WDES indicators. The committee reported they had taken regular assurance from the ongoing Pro-equity work programme, and work was already in progress and there were a number of ‘general actions to help promote and enhance race and disability equity’. However, as reported, the board did not present a cohesive approach to deliver on the Pro-equity programme. Tools and systems to help with actions were in development, and further training for staff to better understand and empower them to tackle forms of discrimination was planned. There was more to be done by leaders in the trust to ensure workforce equity and diversity in their ambition to become a Pro-equity organisation, however, foundations were laid on which to build.

The trust acknowledged the slow progress and had a WRES Improvement Plan 2024-2025 aligned with the EDI Improvement Plan. This outlined action the trust will take to respond to the WRES and achieve improvements against the following themes: discrimination, bullying and harassment (links to the anti-racism working group), recruitment and selections, disciplinary HR processes, compassionate and inclusive leadership an improving the experience of ethnic minority staff. As part of this the trust was, at the time of our assessment embedding cultural ambassadors to support employment processes and practices that involved staff who had a protected characteristic. However, staff fed back that the current resource was not sufficient to meet demand.

The trust had a wellbeing offer in place for staff. There were over 100 mental health first aiders and 156 health and wellbeing champions across the trust. The trust had provided a refreshed support package to the champions with bite sized session on EDI and FTSU to equip them to carry out their roles. Peer support groups were in place for example ‘man chat’ menopause support and a ‘Wellbeing Wednesday’ initiative. Reasonable adjustments processes were in place to support staff in work but some staff in services told us these were applied inconsistently.

The Patient and Carer Race Equality Framework (PCREF) is a mandatory race equity and accountability framework for mental health trusts in England rolled out in 2023. The purpose of PCREF is to support trusts to improve racial inequalities in access, experience and outcomes of mental health care. The trust was in early stages of PCREF implementation through a number of strategies and a paper submitted to board by the PCREF Development group in December 2024, which laid out how implementation would be delivered through 4 workstreams. Progress against PCREF had been slow. Papers presented to board described a starting point for development of the PCREF and further developments would be built into and delivered through the trust’s IIP. At the time of the papers being submitted to board, no additional resources had been identified to deliver PCREF. At 5 subsequent board meetings, and at the people and culture committee meetings, the PCREF development plan was not discussed, accepted or formally agreed (except when referenced in a review of the Assertive and Intensive Community Mental Health Treatment review paper, May 2025). The 2024/25 Quality Account mentioned the PCREF in the context of coproduction with those who used services, and thereafter stated the trust had ‘proposed a development plan’ to implement PCREF. The Board Assurance framework had references to PCREF programme, but little or no detail specifically associated on its risks, assurance and actions. Operationally the Trust had implemented changes in governance, leadership integration and developed feedback mechanisms for patients, carers and the community including two public facing events alongside the PCREF national lead. However, during our interviews of the executive team and most senior leaders, they were unable to spontaneously describe the headline diversity data of their workforce and could not speak actively how to implement PCREF with the patient at the centre of their workforce, although they knew where to access it.

The trust had made significant steps to improve the governance and accountability structure, appointments to key positions and realignment of portfolios and responsibilities. Executive leaders had recognised the rationale and necessity for change and the context in which it was needed. This meant the trust was in the early stages of regrowth and we saw a positive impact the changes had in some areas of working towards the trust strategic direction. However, there were significant gaps in some key areas of oversight, for example Mental Health Act oversight, an executive lead for learning disabilities and autism.

A national review of the trust took place following a significant event in the summer of 2023. In addition, an external audit in April 2025 (of the time period to year end March 2025), identified areas of significant weakness in governance arrangements which highlighted governance arrangements did not allow for effective committee scrutiny and decision making. This had also been identified in 2023 / 2024 and had continued into 2024/2025.

The trust embarked on a significant change management process in March 2024. A total revision of the leadership structure, governance and accountability structure followed, and the trust made significant changes to its lines of accountability, reporting and strategic oversight.

As recent as July 2025 the new operational and executive structure was formally presented to board as part of a wider accountability framework. Formal approval was due to take place by board in the September 2025 meeting. Senior leaders told us the previous structure was fragmented and complex with multiple groups with overlapping roles. Escalation pathways were unclear. This meant the change now provided the trust with an improved and more effective escalation and accountability pathway, ownership of areas of responsibility for all levels of senior leaders in the trust from ward, to care group to committee to board. However, this still required time to embed and in places, there was overlap of roles, and some executive directors did not always collaborate effectively to deliver strategic objectives as described earlier in the report. For example, oversight of the Mental Health Act legislation was fragmented, originating from a quality perspective and reporting to a committee instead of operating within its own defined framework. This meant mental health act issues within the trust were not actioned in a timely way and learning from issues was not always shared robustly.

The accountability framework had 2 parts, one for corporate assurance and another for management of the trust. Within corporate assurance, the trust had 5 committees. At the time of our assessment, these were Quality Committee, Finance Committee, People and Culture committee, Audit and Risk committee and the Integrated Improvement committee. Executive Directors and NEDs had portfolios that ensured they led and had responsibility for these committees. Two committees (quality and finance) had a set of sub committees; for example, the quality committee had a patient safety and learning from deaths group, and a quality and effectiveness group. Each of these subgroups in turn had meetings which escalated issues to their respective committee. 6 meetings fed into one of the 2 sub committees and 8 meetings fed into the other. Two subgroups fed into the finance committee, and these were the digital strategy group and the health and safety committee. The three remaining committees had no subgroups which escalated into them.

The structure in relation to the management of the trust stemmed from the executive leadership team (ELT), with subgroups of an extended leadership team, and an integrated improvement board. Under the ELT were 4 subgroups, and all care groups fed into one of these (Quality Performance Management Group). Five groups fed into the integrated improvement board, but there was no direct report to the relevant committees; for example, the people and culture programme board did not have a direct line of reporting to the people committee. The finance and productivity programme board did not have a direct reporting line into the finance committee. During our assessment, we were not assured that all NEDs and the council of governors used the governance framework to challenge and direct strategic improvement through the relevant committee due to a blurred escalation routes and ability to challenge in the right forums. Some executives indicated a desire to engage more proactively with the council of governors across different areas. They told us they had not involved the council of governors to review and challenge trust data, dashboards and performance. NEDs told us they felt there had been a recent shift to align accountability and responsibility of the leadership team but at times decisions were pushed back and it had been difficult to choose the priorities on which to focus as there had been many that required action.

As part of our information requests for this assessment, the trust provided an updated version of the accountability framework which was to be approved at the September 2025 board meeting. Changes included a direct line of reporting for 6 committees (now included a MH legislation committee) into the board of directors and indirectly to council of governors. 6 groups had been streamlined to report into the integrated improvement board and 8 groups into the extended ELT. Both ELT and IIP board reported directly to the executive leadership team and into relevant committees. Care group accountability also mirrored this structure and reported into the extended leadership team. As this amendment to the accountability framework was so very new, more time was required to embed the structure, but during our assessment we were assured that the trust had made significant steps to redirect and refocus accountability in most areas.

The Trust had a digital health strategy with a scope to outline the business objectives and strategic direction to 2026. The strategy set out key objectives from improving digital care record, public facing services, to understanding data and aimed to deliver through a collaborative approach. The strategy had mostly been mapped to the current Integrated Improvement Plan and was on ‘hold’ at the time of our assessment with no current plans to develop a new consulted strategy focused on patients and community. The Board Assurance Framework maintained a risk focussed on failure to provide and maintain an effective digital infrastructure to meet the growing demands of our services.Our review of the BAF, showed in May 2025 the board recognised despite the appetite for broadening digital opportunities that digital approach was focused on the Electronic Patient Record (EPR), and its funding and the new pharmacy system work was on hold. However, the team had locally developed tools such as patient observation record, developed an AI approach for the trust to try and support operational effectiveness. The trust had significant gaps in funding, next phase strategic direction and capacity to support improving safety and patient outcome and supporting areas such as community health services.

The trust used integrated performance reports, (IPR) submitted to the quality committee and to board, which contained statistical performance charts (SPC). Each SPC could be used to review data per care group, per service or per ward / team. Metrics were used to monitor all aspect of quality of care. Each indicator had an executive summary, KPIs and priority actions to be addressed. The IPR was summarised to board where required if particular escalations were required with specific papers and summaries as needed.

However, not all data was reliable. We found examples during our assessment where data required checks and clarification, and the trust responded that there were inaccuracies in their data. Key stakeholders had shared their concerns with the trust about data quality and reliability. We found examples such as medical staff vacancy rates (May 2025), EDI data, which the trust had to correct and update when we identified discrepancies. We were concerned that data was not sufficiently timely. We found during our assessment, that data presented to board was 2 months in arrears for the September board which had data presented from July 2025. This meant we weren’t assured the board could always responded to current and immediate risks and so had a reactive response rather than a proactive one. Feedback documented in the Quality Report 2024/25 demonstrated partners were also aware of the changes made to the trust’s governance systems and processes following a number of external reviews and audits which had highlighted data consistency issues and asked the trust to take action for better data triangulation.

We saw strong, robust and effective working in the safety and quality governance of the organisation. Patient safety was a leader in strong governance, proactive working groups, with skilled and passionate leaders to deliver high quality care. The changes and investment made to this area of the organisation, included a mortality review group, a family liaison team, an inquest team, restrictive practice groups, safeguarding strategic group and physical healthcare group were crystal clear on the role and impact on patient care. They were visible within the organisation and supported care group leaders to manage their responsibilities within clinical areas in regard to patient safety. The integrated performance report submitted to board covered areas of patient safety including for example patient safety incident response framework (PSIRF) events, investigations such as sexual safety incidents, incidents of venous thromboembolism (VTE), incidents of nasal gastro (NG feeding), restrictive interventions and staffing. Staffing levels featured regularly within committees, quality and safety assurance meetings and board meetings. The trust used a dashboard called “SafeNow” which provided real time visibility of safety metrics and early warning indicators. It monitored trends in all indicators linked to staffing and data was used by the executive team and senior leaders in care groups to determine when risk could be escalated, improve planning and mitigation to control risks.

During our service levels assessments staff in some services told us the escalation process and oversight of staffing issues was not always effective. Staff in some services often reported staffing shortages. Our service level assessments told the trust to take action in the areas where staffing was a concern. Staffing featured as a significant risk in the BAF and in care group risk registers. Board papers and committees showed that there were services across the trust which did not operate within planned levels of staff groups. This meant there were implications for patient care and staff burn out, and there was a correlation to high sickness levels. The trust took steps to over staff hot spot areas, recruitment drives and incentives were used as some of the ways to address staffing risks. A Safe Staffing governance group was established across all 3 care groups to focus on rostering, bank usage and management of staffing. A Safer Staffing report was taken to board in January 2025 to report outcomes of a nursing workforce review. This review made a change to an overall increase in the level of nursing establishments. The IPR for the July 2025 board showed turnover was at 9.5% and had remained under the control limit for 7 months: vacancies 11.7% and sickness at 6.6%. Agency usage was overseen by the Safer Staffing Group which met weekly and was recorded at 1.3%. The trust aim was to eradicate agency usage. Bank usage was at 8% although bank fill rates were 66.9% and had increased during quarter 1 of 2025. The most significant workforce challenges was recruitment to allied health professions where the impact on patient care was wait times in paediatric speech and language therapy and occupational therapy and delivery of meaningful activity in the forensic care group. Recruitment to psychology and medical positions had seen a positive improvement. The trusts’ valuing leadership programme had yet to action ways in which staffing concerns could be addressed. The trust needed to ensure that medical leaders could be as active and embedded in services as their colleagues in other clinical leadership roles and disciplines. Medical leaders did not always have the capacity and the voice in all triumvirate working across the trust. Their workloads had prevented them being a comparable active partner in the triumvirate leadership.

The trust had a board assurance framework (BAF) to manage the principle strategic risks which were aligned to the trust strategy. The BAF aligned strategic risks with committee oversight and was supported by the trust IIP (see earlier) and the trust risk registers and a heat map which provided real time up to date insights into care group and corporate risks. Care groups were able to add risks to location risk registers and as and when the risk scored increased to a significant level, the risk could be added to the trust’s risk register to be sighted and discussed at board level. The BAF had been updated in a board development session in April 2025, where risk appetites were revised. The BAF contained 7 strategic risks, 2 scored at 20 (extreme 20-25); these risks were the failure to achieve financial sustainability and the inability to assure patients public communities and stakeholders the trust can provide high quality, safe, reliable healthcare services. Both these risks had been recently revised.

Two other risks were scored at 16, 3 scored at 12 (high12-16). One risk was entered onto the BAF in February 2020, one in June 2023, one in January 2024, one in May 2024, and 3 entered in May 2025 as revised. There was a range of tolerable risks and target risks which described the boards appetite to manage and mitigate the risks included. 6 risks had scores which the board would tolerate from 20, 16 or 12 down to 12 and one from 12 to 8. This meant the board had a risk appetite to reduce the risk scores and aimed to reduce the risk scores to a target much lower than currently rated. The risk appetite to rescore risks was graded as avoid, low / minimal (2 risks) ultra safe delivery with low degree of risk and limited reward, cautious (4 risks) preference for safe delivery options and a low degree of risk and limited reward; open (1 risks) willing to consider all possible delivery options, likely to result in success with an acceptable reward; seek, or mature. The BAF was regularly discussed at board and specific risks were reviewed through relevant committees. Whilst processes were in place to review local, operational and strategic risks, the appetite of the board was one of cautious and defensive maintenance of the current position rather than to significantly shift focus to proactive and ambitious risk mitigation. Given the position of the trust following external reviews and challenge and forthcoming additional scrutiny, the rationale for this position was understandable.

The trust had a guardian of safe working hours, reports were delivered to the board quarterly. Whilst there were regular meetings to review rotas and working hours, the trust had work to do to resolve issues medical staff had with rota cover, high levels of bank staff usage. Some medical staff described they felt there was a ‘crisis’ in on call stepdown cover within the trust and communication on how the matter had progressed with senior leaders was not always clear.

Pharmacy services within the trust had clear governance oversight and processes with a review that had taken place in the last 6 months. Pharmacy services had a voice at relevant committees and place in the extended leadership team ad were able to escalate risks to care group and trust risk register. Medicines optimisation had good visibility with trust board papers. There was recognition from pharmacy leaders that there was further work required to embed new processes. We heard mixed views from pharmacy staff about working in the trust. All staff expressed a passion for their local team and care for each other and how they gave high quality patient care and felt supported. However, some pharmacy staff told us there was a disconnect between senior leaders in the trust and local teams. Whilst they were positive about their own teams, and the support provide within hem, the wider trust culture was a worry for them within their daily work. For example, we heard about low morale, understaffing, a lack of trust in decision making, communication about decisions was not always robust and under reporting of incidents was a worry. Staff told us of a particular worry in community mental health services, where pharmacy staff have had limited involvement in patient discharge and poor communication with GP teams which meant patients do not receive the best panned discharge with the correct medication. Staff felt this stemmed from a nervousness to discharge from care back to community services following the significant events of summer 2023.

Leaders at the trust were invested in building relationships, understanding perspectives and constructively engaging with partners within integrated care boards, place-based partnerships, provider collaboratives/any other relevant forums, including primary and social care partners. The trust had executive leader representation as members of the system Integrated Care Board, the Integrated Care System, and various working groups, specific meetings and boards to represent the trust within the community, the wider health and social system.

There was effective oversight and governance of partnership arrangements which ensured information was shared between key stakeholders and partners. The trust was part of 4 Nottingham and Nottinghamshire Place based Partnerships and worked with the voluntary sector, social care, county and district councils, county safeguarding services, primary and acute care services to help improve outcomes, improve access and health inequalities. As lead for the South Nottinghamshire Place Based Partnership the trust has helped to deliver projects on falls prevention in neighbourhood areas, the use of technology to support people to stay in their home’s community development workers in integrated neighbourhood teams and expanded social prescribing programmes.

The trust played an active role in a number of provider collaboratives within the midland’s region, including adult eating disorders, child and adult mental health services and perinatal services. It was lead commissioner for IMPACT (an NHS-led provider collaborative that provide specialised mental health services) across 5 regions in the Midlands. The collaborative aims to improve patient pathways between health, social care and the criminal justice system, through transforming clinical models and ongoing service development. The trust was the lead provider for forensic services for East Midlands, and in the past 2 years has made a significant reduction in the number of people receiving care out of area. The trust reported 7 out of area placements at the end of May 2025 (reduced from 36 in March 2023), the highest level since September 2024, the third consecutive month over the target of 0.97 patient beds were purchased from independent mental health providers as of the end of May 2025 four successive weeks above the trusts’ upper control limit.

The trust had collaborated with stakeholders, including oversight partners, and system partners to develop services. Collaboration with those who use services, staff, families and carers have taken part in service redesign programmes when restructuring and re-designing new services and pathways. Meetings took place with key stakeholders to develop a staff reference group, a patient carer and family reference group who were consulted and able to provide views and perspectives on the delivery of changes to services. We saw examples of strong relationships with local agencies such as police and GPs, local universities and other high secure hospitals and from these relationships, initiatives had developed which helped strengthen areas of service delivery in care groups. However, we noted the trust had made a tactical decision to focus on relationships with regulatory stakeholders and focus less on local partnerships. This was led by how the trust managed its immediate priorities and increased scrutiny in its services, how to manage external focus on the way the trust operated rather than how to collaborate in relationships with the aim to hold the patient at the centre of this partner working. For example, the trusts’ communications were predominantly focused on managing and responding to national and local media stories, which took energy and focus away from proactively promoting key stakeholder relationships.

Leaders told us the trust had recognised there was work to be done in addressing health inequalities, but this work was not as prominent as it could be. The trust strategy included addressing health inequalities as part of enabling strategies, however senior leaders recognised that further work was needed to understand inequalities and meet the needs of specific communities across the trust’s footprint. There was a strong health inequalities working group supported by a joint appointment with the council of a public health consultant. The PCREF work already started in the trust had made efforts to identify key target areas of inequality however, this was slow to develop with no clear links to trust processes or comparisons to national inequalities data, for example in restrictive practices and community treatment orders. Patient, carer and family forums were in their infancy to improve feedback on how services could improve access for minority groups. Some work streams had been developed and implemented key actions to make improvements for vulnerable groups of the community, such as access to crisis care for black males, and the formation of the youth impact board, the children’s and young people’s physical health integration project. Another the virtual ward being developed for Clozapine initiation and monitoring in more deprived areas of the patch.

The trust worked with partners to safeguard people. Mental health statutory social work with adults whose main presenting needs were associated with their mental health was delivered by Nottinghamshire County Council and Nottingham City Council, under section 75 of the national Health Service Act 2006. All safeguarding concerns were received and managed via the respective local authority adult safeguarding services and the trust, as a partner organisation would take the lead on safeguarding enquiries where appropriate. included all aspects and sources of harm, including physical and psychological abuse, and exploitation. The trust reported 2421 safeguarding incidents were reviewed by the trust safeguarding team between June 2024 and July 2025. 163 were referred to local authority under Section 42 of the Care Act for investigation. In the month of May 2025, 199 safeguarding referrals were made into the trust incident reporting system (153 adult referrals, and 46 child referrals). The number of allegations of abuse made against People in Positions of Trust (PiPOT) increased to 72 for May 2025 those meeting the threshold for investigation was 38. The trust had embedded robust systems and governance arrangements within the patient safety team to review, investigate and share learning from PiPOT reviews, serious case reviews and mortality reviews.

Robust governance processes were in place for the management of complaints. The complaints team were well established and had good visibility within the care groups across the trust with the aim to develop awareness, knowledge and ability of leaders to carry out complaint investigation, informal resolution and how to escalate concerns. Complaints were reported through care groups and dashboards showed complaints data within integrated performance reports. The trust target to respond to complaints was 85% and as of June 2025, the trust compliance was 78%. 1481 complaints were received in 2024/25, of which 509 were upheld. Over time the highest number of complaints received between August 2024 and July 2025 was in May 2025 at 142 complaints received, driven mostly by the increase in Community Health Services, where Community Health Services showed to have received its highest total of complaints in May of this year at 71 received in that month, though there was also an increase in Forensic Services complaints at that time. Community Health Services saw an overall steady trend; however, Forensic Services saw a slight increase over time and Mental Health Services showed a slight decrease over this time period. Reasons for delays to response times were primarily due to the complex nature of complaints and the time taken to investigate, investigators requiring extensions, or changes in staff completing the investigation. The Director of Nursing had commissioned a review of the trust complaints procedure with new terms of reference with the aim to create a new set of recommendations on how to increase clinical expertise to answer complaints in a more timely way and improve service user involvement to provide more impact to deliver change in services for better care delivery.

The trust had been active in delivering key projects developed in partnership with local communities, those who use services and local stakeholders which have been planned, rolled out or delivered. These include a project to better respond to the needs of young black men reaching crisis point and detainment; tackling loneliness collaborative, improving care planning together collaborative group, carers, family and friend events in February 2025, patient and carer information group, and a Youth Impact Board which worked with young people with lived experience of services from the trust to have a role in developing and overseeing mental health services for younger people.

There was a disconnect between the vision executive leaders had of the organisation and its position of being a learning organisation, to how learning and changes in practice had been implemented in some services. Executive leaders told us the trust was a learning organisation. Leaders described a move from investigation and blame to a focus on learning, listening and change. The trust board were clear that data capture, analysis and evaluation were integral to their belief they were a learning organisation. We saw evidence that whilst the trust believed a learning organisation vision and culture shift was active and dynamic, we saw areas where in practice, learning and a shift from blame culture was not taking place as the board may have hoped.

The trust had undergone a significant level of scrutiny since June 2023, both regulatory, through a system wide lens, national and financial oversight. The trust had been open to each and every review, investigation and thematic review it had been subject to, despite the pressure, and burden it had placed on the senior leadership team. During our regulatory assessments, the board responded swiftly and openly to areas of improvement required, and we were impressed with the level of engagement, especially from the CEO and DoN in all areas where improvement was required. This meant any impact to those who used services was reduced and mitigated in a timely way. National investigations and thematic reviews resulted in multiple oversight and action groups to address findings and recommendations. We saw how the strategic reset had been triggered from such thematic reviews and the trust committed to transfer learning between care groups. During our assessment, and interviews with executive leaders, we recognised the ambition of the trust to be a proactive and committed learning organisation and in the absence of such scrutiny, the trust would have progressed more swiftly with its ambition to embed its learning culture throughout the trust.

There were departments such a patient safety, facilities, safeguarding and IPC teams in the trust, led by enthusiastic and competent leaders who had learning and service improvement at the centre of their roles. The IPC team had innovative ways to share results of audits, compliance and engaged with care groups to ensure teams learned to improve practice. The facilities department held patient care at the centre of their role to ensure whatever role was carried out, staff knew the impact they had on patient care.

During our assessment of services between May 2024 and July 2025, during our regular regulatory role, engagement and a review of significant incidents and deaths since January 2022, we saw that action plans, quality improvement plans and learning was identified through investigations, was not aways co-ordinated and managed centrally, to ensure a joined up and strategic approach to learning. The trust used clinical managers from care groups to undertake investigations, and delays to the process were influenced by workloads, availability and daily pressures of their role. Learning was not always shared effectively and staff told us in places; there was a blame culture. In the 2024 NHS Staff Survey, the trust scored significantly worse than previous year results for the people promise element ‘We are always learning’. Each care group showed worse results for this element, as did the corporate functions of the organisation. Whilst the survey results showed the trust encouraged staff to report errors, incidents, and near misses, (85% of staff agreed) 60% of staff felt the trust took action to ensure they do not happen again and 58% agreed the trust gave feedback about changes made in response to reported incidents.

The patient safety team had recently made positive strides to embed learning from incidents. The trust had invested in the expansion of the team and there had been a realisation that patient safety was the business of everyone in the trust. Feedback from freedom to speak up cases, and complaints had led the organisation to invest in this area. Three safety managers were in post, one for each care group, and 8 clinical reviewers had been recruited specifically to review incidents. Family liaison posts had strengthened relationships with families and carers. The new and improved systems to learn from deaths, inquests, patient safety incidents and alerts from national bodies were more effective and better highlighted learning that was disseminated in a more co-ordinated way and used to improve the quality and safety of care and treatments. The trust’s revised governance, oversight and processes for learning from deaths and incidents now focussed on a holistic review of patients who had been harmed or died whilst in the care of the trust. More recent reports from incident investigations and death reviews showed that action plans, quality improvement and learning was identified and used to bring about improvements for other patients.

The implementation of the PSIRF had been implemented but was yet to be embedded fully. Voices of families had made a huge impact on team who attended learning events, and this helped bring levels of impact to those who had responsibility to change service delivery for the better. The team described how compassionate engagement with families, patients and carers was important to drive improvement in services. The teams spoke passionately about how they hoped to improve the focus to a positive patient safety culture, to shift culture to ensure staff held patients at the front of learning in the organisation and move away from a blame culture that used to exist, and whilst it remained in pockets, it was an improving picture. Patient safety was now a focus rather than incident management. Those who used services were involved, where appropriate in ‘after action reviews’ and their voice was weaved into investigation reports. We saw that patient safety data was robust, but there was not complete assurance within the team that other data collected by the trust (for example staffing data, which was often used to compare against safety incidents) was accurate and the patient safety team had developed ways to ensure the data produced around incident reporting was timely, and accurate.

Joint investigations had taken place with key partners in the local system, for example local hospital trusts, ambulance services and coroners. Relationships had been strengthened in recent months, as investigators had made links to ensure thorough processes and reporting was as good as it could be. Clear lines of accountability of reporting incidents, and patient safety metrics to board were evident.

Through our assessment of services, we saw examples where communication about learning, led by corporate services was not as effective as that of the patient safety team who had good relationships with care groups. Staff in some services told us they had been instructed to manage patient risk in specific ways by senior leaders but did not understand the reasons for some decisions that had been made. We found scenarios where decisions had been made, about service delivery which directly impacted patients negatively, or impacted staff morale as decision made had not been explained. For example, blanket restrictions across inpatient services, were not appropriate in rehabilitation settings; decisions made to pause eradication of dormitory work in older adult inpatient services was not communicated clearly and staff felt disappointed their ideas and input into service improvement had not been recognised.

People using services had started to be more involved in improvement and innovation, and consultation with those who used services, families and carers was improving and becoming more frequent. Our assessment of services showed some care groups and individual services did this better than others. A recent appointment to a position at associate director level for participation, coproduction and patient and carer experience was in early stages of defining its remit and direction. The trust’s policy for involvement of patients, service users and carers, (version 7) was dated 2024, with a review date due for December 2025. A policy review commenced in January 2025 as part of the involvement and participation strategy with the plan to have a new policy in place and approved by December 2025. The trust had a draft strategy to support the focus needed in the organisation with coproduction and engagement across all areas, which in the first instance the newly formed patient and carers reference group had sight of. Having taken trust complaints into the portfolio, the associate director had plans to further develop the patient survey to improve completion rates. Other areas for development included increasing the number of volunteers to represent the demographics of the local population, increasing the current 400 participation workers in the trust.

The trust was open to receiving feedback from patient and family surveys and used an online feedback survey to collect and learn from feedback. Staff surveys, listening events and anonymous feedback systems allow the senior leadership to gather feedback from staff to help influence service delivery. Performance metrics and enhanced staff engagement helped senior leaders monitor the effectiveness of the new governance arrangements and regular feedback from leadership teams provided feedback to the board on care group performance. The trust had plans to improve staff engagement in the next staff survey, and the board told us they were committed to strengthening partnerships with staff to help build a better culture and compassionate leadership.

The trust used quality improvement (QI) through its departments and services. Individual teams and services used a quality improvement framework to improve service delivery and aspects of their work. The trust had been assessed as ‘developing to progressing’ across the NHS IMPACT maturity matrix. This meant the trust was growing in maturity to continuous QI, and was due to the improved leadership engagement, a QI team with expertise and increased presence in care groups, and QI implementation plan and the commitment to coproduction s already described. Over 2000 staff had been trained in a QI model, and levels of QI training were tailored to meet the needs of teams. However, QI was somewhat uncoordinated in the trust, and senior leaders we spoke with told us the trust needed to do more work to bring together QI in a co-ordinated way. In May 2024 a key recommendation from the trust’s QI readiness assessment advised that a redress of the balance between bottom-up generated QI initiatives and top-down initiatives required closer alignment. The board had identified goals for QI over the next 12 months and to ensure QI was refreshed into the IIP at the next review. Priorities included planned training for leaders in QI to gain skills to be able to support teams and sponsor improvement. Middle managers were to be identified to work as QI coaches to support QI practice. Governance for QI was planned to feed into the Quality and Clinical Effectiveness and Oversight group as mart of the new accountability framework.

The research function of the organisation was split across 2 teams, under the executive chief medical officer and was hosted by the University of Nottingham. There was a trust research and evidence team of 10 staff, whose function was to ensure any research developed within the trust was compliant with national policy and best practice. The second team was the Institute of Mental Health (IMH) team, of 12 staff who were responsible for research grant applications, contracts and administrative support for research projects. This team was governed by a financial arrangement agreement between the trust and a local university and a MOU. This MOU had expired and was being reviewed. There was a disconnect between the IMH team and the trust and staff told us there was inequity, negativity and financial complexity to the arrangements, which impacted on both teams and the collaboration in the arrangement. At the ELT meeting of June 2025, a report was presented to make recommendations on a number of options available for consideration to improve the position of research and innovation in the trust. However, this had not been discussed at board in the July 2025 private or public meetings, despite the financial implications and risks associated with the options presented. There was further work for the trust to do to realign, consolidate and embed research and innovation objectives.

The trust participated in national audits as needed, had an internal audit schedule and received external audits as required. The audit and risk committee were sighted on audit schedules, outcomes and actions of each audit. Minutes of the June 2025 audit and risk committee summarised a 2024/25-year end position of moderate assurance from internal audits, with high and medium risk actions that made up 54% of all actions. However, it was noted there was an imbalance with BAF areas that had received significant assurance and could lead to ‘a skewed perception’ of risk and questioned whether the current audit approach gave a fair and proportionate representation of strengths and challenges across the trust. The committee had recognised the significant work ahead for the trust to embed the new governance and accountability structure.

The trust had used and achieved various nationally recognised accreditation schemes to ensure they met definable standards in key clinical areas. Within child and adolescent mental health services, services for people with learning disability and autistic people, older adults’ mental health services and acute mental health inpatient services, quality network accreditation schemes were in place. The trust’s mother and baby unit had remained accredited to the Perinatal Quality Network, accreditation awarded by the Royal College of Psychiatrists. The trust’s Healthy Family Team achieved the UNICEF Baby Friendly Initiative Gold Sustainability award, in June 2024, a nationally recognised mark of quality care. The rapid response Liaison psychiatry teams re-accredited the service under the Psychiatric Liaison Network Standards (PLAN). Psychological therapies, home treatment teams and forensic services had aligned to national quality networks and recognised accreditation schemes.

The trust had processes to ensure staff accessed professional development and support to provide care. Supervision and appraisal rates were above the trust target of 80%. There as a broad programme of professional development for all disciplines and time was allocated to allow learning opportunities.

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. The trust had an Executive and Non-Executive lead board level lead for the trust’s green plan. Governance for progress against the strategy were monitored by the Finance Committee.

The trust’s ‘10 point Green Plan 2022-2027 – Our Journey to Net Zero’, was approved by board in January 2022. It was aligned with wider system plans, particularly the local integrated care board Green Plan, and these were regularly reviewed and updated in line with national guidance. The Green Plan was clear and was a focused strategy to support the organisation to deliver greener healthcare through resource efficiency and environmental excellence. There was dedicated leadership and team to drive improvements and deliver against actions. However, oversight of the Green Plan was not strategically monitored in a robust way. The trust’s board meetings reported on progress towards the Green Plan as and when specific decisions were required, usually concerning financial implications for specific projects. Board papers, committee papers and key documents such as the capital plan, the 2025/26 operational plan, and the financial plan and the 2025/26 financial recovery plan had no references to the strategic goals of the Green Plan.

Progress against the objectives in the plan were monitored quarterly by a Trust Net Zero Group and chaired by the executive director of finance and estates, supported by a NED. There were improvements noted since 2024/2025 around decreasing the carbon footprint of the organisation and all objectives had recently been reviewed and refreshed and presented to board in July 2025. Priorities for the coming year were clearly articulated and included specific targets against areas such as medication and waste, raising awareness of climate change within patient groups and reducing gas usage. There were processes to track progress against targets and respond to relevant data collections such as the Greener NHS guidance and the Estates Returns Information Collection (ERIC).

Risks in delivering against the trust’s sustainability objectives were clearly recorded on both the Board Assessment Framework and within conversations with senior leaders and were focused on finance and resourcing. Assessment of the risks which may delay the objectives were reviewed by the finance committee and trust board. Alongside the BAF risk, the trust had identified a corporate risk and included this on the trust risk heat map specifically, the risk of failure to comply with environmental legislation and meet sector targets. Board papers and committee papers showed discussions on specific topics such as decarbonisation in services, heating efficiency, and capital bids and financial awards to deliver net zero plans. The initial green pan had set an objective to undertake a trust wide climate change risk assessment, which had been approved by the trust management group in October 2023. This was due to be assessed on the next review of the green plan in August 2025 following publication of the latest version of the plan, dated July 2025.

Efforts had been made to embed sustainability in various ways including training up to board level using an accredited course, quality impact assessments looking at environmental sustainability for projects and proposals and reference to this in recruitment processes such as job descriptions. The trust had over 500 green champions who as part of a network were engaged in the green agenda.

There were several positive examples of how the organisation has driven the sustainability agenda including growing green spaces and developing a role of nature ranger to work across two sites with patients, improved food menus and reduction in food waste, a food waste champion and youth impact board representation at the Net Zero meeting. The facilities team had developed implementation of a new cleaning product which if ingested would be significantly less harmful that usual cleaning products and contributed to the green plan achievements.