Nottinghamshire Healthcare NHS Foundation Trust

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement.

This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The trust had not ensured effective governance systems, leaders were not always capable and compassionate, staff did not always feel safe to speak up, the trust did not ensure workforce equality and had not embedded learning, improvement and innovation across all wards.

However, the trust had a clear direction and values and strong partnership working in the community.

The trust was in breach of regulation for governance at the service.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Leaders ensured there was a shared vision and strategy and that staff in all areas know, understand and support the vision, values and strategic goals and how their role helps in achieving them. The trust’s vision was to ‘make a difference to the communities we serve by delivering the highest quality physical and mental health care to our patients, and by tackling inequalities in outcomes, experience and access’. This was underpinned by 5 core values; Trust,Honesty,Respect,CompassionandTeamwork. The trust developed a 5-year strategy detailing what their priorities are, the outcomes they will deliver and when they will be delivered.It will inform everything from significant service level decisions through to individual objectives for staff with a view to delivering improved outcomes for patients and service users. Staff were aware of the vision and values of the trust.

The evidence showed some shortfalls. Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation.

Leaders at every level were not visible. Although that local leaders were visible and supportive, senior leaders rarely visited the service, with 1 staff telling us they had never felt so disconnected from senior leaders.

Leaders were not alert to any examples of poor culture that may affect the quality of patient’s care and have a detrimental impact on staff. Staff on some wards felt that local leaders were not listening to their concerns about unsafe staffing levels. Staff also shared that local leaders changed the ward rotas without taking staffs’ reasonable adjustments into account. In the 2024 staff survey 83.3% of staff said they had felt unwell over the previous 12 months due to stress at work, 33.3% of staff said the trust did not take positive action for their health and well-being. The number of staff responding positively to the question ‘Has your employer made reasonable adjustment(s) to enable you to carry out your work’ was so low that it did not generate a result. In the same survey 43.7% of staff said they were planning to leave as soon as they got another job.

Local leaders had the experience, capacity, capability and integrity to ensure that the organisational vision could be delivered. Staff spoke highly of local leaders and most of them were experienced in their roles.

The evidence showed some shortfalls. People did not always feel they could speak up and that their voice would be heard.

There was a poor culture of speaking up and not all staff could actively raise concerns and feel supported, without fear of detriment. We reviewed the staff survey from 2024 completed by staff from Redwood 1 ward, Redwood 2 ward, Cedar ward, Rowan 2 ward and Willows ward. Only 51% of staff felt safe to speak up. Staff on Rowan 1 said they raised concerns about unsafe staffing to the Freedom to Speak Up Guardian (FSUG) but heard nothing back. However, staff we spoke to told us they could speak up to their managers.

Leaders encouraged staff to raise concerns and promoted the value of doing so. The trust reported they had a lead FSUG and a deputy FSUG. The trust received 8 concerns via their FTSU routes from staff on the Acute wards and PICU between 15 December 2025 and 29 January 2026. Staff raised concerns about bullying, discrimination, policies and procedures, safety and wellbeing, inappropriate attitudes/behaviours and leadership and management. Leaders reported taking appropriate action, including instigating HR processes, use of mediation and escalating to senior leaders.

The evidence showed some shortfalls. The service did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Leaders did not always take action to prevent and address bullying and harassment at all levels and for all staff, and did not focus on those from excluded and marginalised groups. The trust shared the 2024 staff survey in which 43.3% of staff said they had experienced discrimination from managers or colleagues. Of these, 91% said it was because of their ethnicity.

Leaders took active steps to ensure staff and leaders were representative of the population of patients using the service. We observed staff on the wards to be reflective of the communities they served.

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

Governance, management and accountability arrangements were not effective. Staff did not always understand their role and responsibilities. Managers could not always account for the actions, behaviours and performance of staff. We identified serious concerns in relation to management of risk on some of the wards, which had not been identified and acted on by leaders. We identified concerns in regard to how some staff, including local leaders, treated patients.

Data or notifications were consistently submitted to external organisations as required. The trust submitted data and notifications to CQC as required.

There were robust arrangements for the availability, integrity and confidentiality of data, records and data management systems. Patient information and service level data was held securely and accessible for all staff.

The trust shared a governance structure which included ward governance meetings feeding into service level governance which then fed into various meetings and committees for safety, quality and improvement. The trust shared recent ward governance meeting meetings for Elm and Beech wards (we did not visit Beech ward as part of this inspection). Attendees discussed care plans, risk assessments, MHA section 32 rights, care consent, observations, staffing, training, audit feedback, patient and carer feedback, MDT feedback, complaint’s themes, feedback from MHA and CQC visits, QI updates, patient safety, actions and escalations.

Leaders implement relevant quality frameworks which included a comprehensive audit process. The trust reported staff completed a range of audits covering care records, premises and equipment, medicines and restrictive practices. For the wards we visited, the trust reported a compliance rate of 91%. However, we were not assured about the quality of these audits due to the concern we identified on inspection.

The trust reported 18 risks on their risk register for the ‘adult mental health inpatient and crisis’ care unit. This care unit includes older people’s wards and crisis services. Leaders rated 10 risks as red, 7 as amber and 1 as yellow. Red rated risks included a lack of physical health provision, lack of SaLT input, ligature risks, patients smoking in non-designated areas, staff not completing patients’ observations as prescribed, key information not being handed over when patients were transferred between wards. We found evidence of some of these risks during our inspection, for example, concerns about physical healthcare. However, other concerns we identified were not captured on the risk register, these included poor management of risk and restricted items and staffing not always being safe and effective. The trust advised they reviewed risks every 3 months as a minimum.

The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Staff and leaders worked in partnership with key organisations to support care provision, service development and joined-up care. This included working with other health and social care providers and local commissioning bodies. The trust partnered with NHSE’s ‘Advancing Mental Health Equalities Taskforce’ to support other PCREF sites in their development.Staff from the wards that implemented the ‘Culture of Care’ programme partnered with another trust to share best practice.

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

Staff and leaders did not always have a good understanding of how to make improvement happen. Although the trust introduced the ‘Culture of Care’ programme on Redwood 2, Rowan 2, Fir and Elm wards in 2024, we found little evidence of this having a positive impact on the wards we visited as part of this inspection.

Processes to ensure that learning happens when things go wrong were not effective. Leaders did not always encourage reflection. We identified missed opportunities to learn lessons from incidents, including staff not always involving patients. Some staff raised concerns that they did not have the opportunity to attend reflective practice sessions due to staffing pressures.

Staff and leaders engaged with external work, including research. The trust reported 3 open research projects for adult mental health inpatient wards. These were ‘Clozapine- off licence prescribing’, ‘Evaluation of a Positive Behaviour Support (PBS) Pathway pilot on a Female Acute Adult Mental Health Ward’ and ‘Service users experiences of receiving post incident reviews in an Acute Inpatient Adult Mental Health Setting’. Senior leaders told us they hosted the NIHR HealthTech Research Centre Mental Health and were a partner in to the NIHR Mental Health Translational Research Collaboration through which they benefitted as a centre in early psychosis and mood disorders. The trust advised they had a Trusted Research Environment (TRE) in the shape of our CRIS (clinical record interactive search) system.

Some staff were supported to prioritise time to develop their skills around improvement and innovation. Staff on Rowan 1 implemented the ‘Purposeful admissions safer transitions’ QI project. This involved looking at inappropriate admissions, for example, a patient was admitted with physical illnesses, and they were able to discharge them to an acute hospital setting. The trust reported QI projects on other wards including ‘reducing enhanced observations’ and a ‘violence and aggression collaborative’.