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 hospital 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 Requires Improvement. At this assessment the rating has remained the same.

Leaders did not always have the skills, knowledge and experience to perform their roles. Staff did not always know and understand the provider’s vision and values and how they applied to the work of their team. Staff did not always feel respected, supported and valued. Governance processes did not always operate effectively. Performance and risk were not always managed well. Teams did not always have access to the information they needed to provide safe and effective care. Staff did not always collect and analyse data about outcomes and performance. They did not always use this to embed improvements.

The hospital is in breach in breach of legal regulations in relation to good governance.

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

The evidence showed some shortfalls. The service did not always have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Throughout the assessment, we spoke with staff who demonstrated passion and commitment to providing the highest level of support to patients at the hospital. Staff were familiar with the trust's values; however, they did not consistently demonstrate a clear understanding of the hospital's senior leaders vision when it came to staffing establishments.

Staff openly discussed the pressures they faced and expressed concerns about how senior leaders were managing workforce challenges.

Staff consistently told us that there were not enough staff on the wards and that the established staffing levels did not reflect the needs of patients. In contrast, senior leaders told us that they regularly reviewed staffing establishments and considered them appropriate for the needs of the hospital.

We reviewed incident data from January 2026 to April 2026 and found that 611 of the 1,561 incidents recorded (39.1%) related to staffing issues. Staff had identified either a "red staffing event" or "suboptimal staffing" as a contributory factor in these incidents.

Staff and senior leaders provided differing explanations for the staffing pressures. Leaders told us that staffing challenges primarily resulted from unplanned staff sickness and changes in patient acuity. However, staff attributed these pressures to insufficient establishment levels. Several staff members summarised their concerns by stating, "We need more staff."

We reviewed workforce data and found that the hospital's vacancy rate was 7.95% at the end of March 2026. Leaders told us this represented an improvement from 11.81% over the previous 12 months. At the time of our assessment, the hospital employed 1,264.87 full-time equivalent staff, representing a headcount of 1,387 employees.

Despite the reduction in vacancies, the feedback we received from staff was not consistent with the explanations provided by senior leaders regarding the causes of staffing pressures. The differing perspectives between frontline staff and senior leaders, together with staff concerns about workforce levels, meant we were not assured that the senior leadership team had effectively communicated the provider's vision, workforce strategy, and rationale for staffing decisions across the hospital.

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 did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

We identified a disconnect between senior leaders and frontline staff regarding the rationale for some operational decisions and the day-to-day reality of staffing pressures. Staff told us that they sometimes felt pressured by site management to move between wards and cancel planned sessions with patients in order to address staffing shortfalls.

Previous assessments highlighted concerns that senior leaders were not always visible to staff working on the wards. Leaders acknowledged that further work was required in this area and had introduced staff forums to improve communication and engagement. These forums provided opportunities for staff to speak directly with senior leaders, raise concerns, share suggestions and discuss issues that mattered to them.

At the time of our assessment, only a small number of forums had taken place. Senior leaders told us they believed the forums had already improved engagement with staff. Leaders had also introduced ward communication books to enable staff who could not attend the forums in person to record questions, concerns and suggestions for consideration by the senior leadership team.

However, during our night visit, several staff told us they were unaware of the forums and did not know there was a process for contributing if they could not attend in person. This suggested that communication about the initiative had not reached all staff groups.

While leaders had introduced initiatives to strengthen engagement between senior leadership and ward-based staff, these initiatives remained in their early stages. As a result, we could not determine whether they would achieve sustained success in improving communication, increasing leadership visibility and reducing the perceived gap between senior leaders and frontline teams.

We found that senior leaders had the skills, knowledge and experience required to perform their roles effectively. Although organisational changes had resulted in some adjustments to the leadership team, each leader demonstrated extensive knowledge and experience of managing a high secure hospital. Many leaders had worked at the hospital for a significant period, providing stability and continuity.

Senior leaders also oversaw the trust's forensic services, which enabled them to collaborate with and seek support from leaders working across similar services within the trust.

During our assessment, we spoke with ward managers who, like their senior leaders, demonstrated knowledge, experience and compassion in their roles. Ward staff spoke highly of their managers and valued the support, guidance and leadership they provided. However, some ward managers were absent due to sickness, which staff told us had affected their teams.

We also observed positive leadership practice during our night visit. Members of the site management team spent time on each ward, checked on staff welfare and asked whether staff required any support.

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

When concerns are raised, leaders investigate sensitively and confidentially. However, lessons were not always shared and acted on.

Staff felt able to raise concerns and believed leaders listened to them, many told us they had not seen meaningful changes as a result of doing so. This led some staff to question whether the organisation had effectively acted on the concerns they had raised.

Throughout the assessment, staff demonstrated an understanding of how to raise concerns and speak up. They were aware of the Trust's Freedom to Speak Up Ambassadors and understood how to access this support. We also received feedback from staff who wanted to share their views and experiences regarding the current operation of the hospital.

Staff told us they felt able to raise issues with senior leaders and reported that leaders had arranged meetings to discuss their concerns. We found that staff were willing to speak up when they identified issues and that they often did so because of the impact those issues were having on patients and the quality of care being delivered.

Staff demonstrated openness and confidence in raising concerns, and we found no evidence that staff were reluctant to challenge issues affecting patient care.

Patients, families, and carers had opportunities to provide feedback about the hospital in ways that reflected their individual needs. We were told that the hospital regularly distributed patient and carer surveys, reviewed the feedback received, and took action where appropriate.

The evidence showed a good standard. The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

One staff member shared concerns about equality of opportunity within the hospital. Based on their personal experience, they felt that staff from ethnic minority groups were less likely to be shortlisted for opportunities and believed that systemic racism existed within the organisation. They told us that, in their view, "every minority is seen as an outsider." Leaders shared staff ethnicity data which demonstrated an increase in diversity throughout 2019 to 2026 notably at Band 5, Band 8C and Band 8A nurse level.

Staff provided examples of the hospital supporting flexible working arrangements to accommodate personal circumstances, including caring responsibilities and health conditions. We also heard that ward managers implemented reasonable adjustments to support staff in carrying out their roles effectively.

However, some staff expressed anxiety about the future of their wellbeing support. Staff told us that some wellbeing plans were coming to an end, while others had been informed that such plans were no longer being considered. This uncertainty contributed to staff concerns about the level of support available to them.

We were told that the hospital and the Trust had equality and diversity champions, including representatives and networks for LGBT+ and ethnic minority groups.

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.

We carried out routine assessments of the hospital throughout 2025, during which staffing and environmental issues remained areas of concern.

During this assessment, we identified several concerns that had been raised during previous assessments. This demonstrated a pattern of inconsistent compliance and limited evidence of sustained improvement. We were not assured that senior leaders had acted effectively on feedback from previous assessments, as many of the concerns remained. We learned that leaders had not always responded promptly to feedback arising from Mental Health Act reviews and Independent Care (Education) and Treatment Reviews (IC(E)TRs).

While we identified examples of good practice and have highlighted these throughout this report, we found that improvements had not been embedded consistently across the hospital. We observed variation between directorates and wards in key areas of practice, including care planning, consent recording, and the provision of accessible information. Although patients on different wards had different needs, we did not see a consistent organisational approach to these fundamental aspects of care delivery.

Staffing remained the most significant issue affecting the hospital. We were not assured that leaders had implemented sufficiently effective systems to address workforce pressures. Staffing shortages continued to result in staff being redeployed between wards and, in some cases, prevented staff from meeting their own basic needs, such as taking breaks or accessing toilet facilities during shifts.

One staff member told us that they had worked across every ward in the hospital during the previous year and spent very little time on their substantive ward. They explained, "It is hard to understand the patients with so many changes." This reflected wider concerns raised by staff about continuity of care and their ability to build meaningful therapeutic relationships with patients.

We were concerned that the ongoing movement of staff across wards limited the hospital's ability to provide the full range of therapeutic care it was capable of delivering. Instead, staffing pressures appeared to result in some patients receiving only basic levels of support rather than the comprehensive and recovery-focused care the hospital sought to provide.

Staff from the Therapy, Education Staff (TES) and Active Lifestyle teams told us that senior leaders had not implemented a system to record temporary redeployments, often referred to as managed moves. These occurred when site management directed staff to work on wards to support staffing shortfalls. As a result, teams had developed their own methods for recording these moves because no central system existed.

We also learned that the hospital did not record redeployments lasting less than four hours. This meant leaders could not capture the full extent of staff movement across the hospital. Consequently, we were not assured that senior leaders had access to complete and accurate information about staffing deployment or the operational pressures affecting wards.

Although leaders had taken some steps to address longstanding concerns and we identified isolated examples of positive practice, we did not find sufficient evidence of sustained and embedded improvement. Staffing pressures continued to affect patients and staff across the hospital, and significant variation remained in how directorates and wards delivered and recorded care. As a result, we were not assured that governance systems were consistently effective in identifying, addressing, and learning from known risks across the hospital.

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.

We found that senior leaders engaged effectively with external stakeholders, including commissioners. As part of the operation of a high secure hospital, leaders also maintained strong engagement with the National Oversight Group and welcomed feedback, challenge, and guidance arising from meetings and visits.

Ward leaders had established strong working relationships with other care teams, which supported effective communication and facilitated smooth discharge planning for patients.

Following the Section 48 review, leaders developed close working partnerships with the other two high secure hospitals in England. These partnerships encouraged shared learning and collaboration across the hospital. Leaders also provided ward staff with opportunities to visit the other hospitals as critical friends, enabling them to share good practice, gain new perspectives, and support service improvement.

During the assessment, we found that the hospital provided opportunities for patients to meet with leaders and share feedback about their experiences of care and treatment. This demonstrated a commitment to engaging patients in the development and improvement of the hospital.

Following the Section 48 review initiated by the Secretary of State in January 2025, leaders implemented a recommendation to establish "critical friend" arrangements with the other two high secure hospitals in England. Leaders told us that this had been a productive and successful way of working and that they valued the opportunities for shared learning, challenge, and improvement that it provided.

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.

Throughout the assessment, we heard about several new initiatives that senior leaders had introduced to address workforce challenges and reduce staff sickness. Leaders had implemented a range of measures to help staff understand the impact of short-term sickness on services and patient care. They also worked with ward managers to support them in having constructive and supportive conversations with staff about attendance and wellbeing.

Leaders had also identified opportunities to improve how staff managed risk on the women's wards. At the time of our assessment, leaders were developing a quality improvement project known as Dynamic Environmental Risk Management (DERM). The project aimed to reduce reliance on enhanced observations by adopting a more dynamic approach to risk management, focusing on the interaction between patients, staff, and the ward environment rather than increasing staffing levels to manage risk.

Although the project remained in the planning stages during our assessment, project leaders had already undertaken staff engagement activities on the wards selected for implementation. They had also begun engaging with patients to support the development of the initiative. During our time on the wards, we heard staff discuss the project and saw evidence that leaders were actively promoting and explaining its aims.

While significant work remained before the project could be fully implemented, leaders demonstrated enthusiasm and commitment to the initiative. They clearly articulated the potential benefits of the project, including improvements in patient care and a reduction in some of the staffing pressures facing the hospital.

However, we were aware that staffing challenges had existed for many months prior to our assessment. Leaders had introduced several initiatives including DERM. Initiatives such as Clinical Director-led observation review, review of safe staffing, absence management quality improvement project, roster management improvement work. Although leaders had introduced measures to support workforce stability, and additional initiatives were under way and some in development, we were not assured that these actions had yet delivered significant improvements. Staffing pressures and their impact on patients and staff remained evident throughout our assessment and continued to affect the delivery of care across the hospital.

The Hospital was part of ‘The High secure Collaborative’ which included the 2 other High Secure Hospitals in England and the Scottish High Secure Service. Leaders told us they had done this through a range of formal collaborative forums designed to support benchmarking, shared learning, service development and continuous improvement. Leaders told us the collaborative met quarterly, bringing together representatives from all services to share updates, discuss challenges, highlight achievements and identify examples of good practice. This forum also facilitates routine review and benchmarking of performance data across the English High Secure Hospitals through the Secure Services Quality Dashboard (SSQD), to which each organisation contributes. In addition, leaders told us that they attend the High Secure Clinical Practice Forum which meets on a quarterly basis. However, with all this in place our findings did not assure us that the hospital consistently benchmarked its practices against recognised good practice across the high secure network.

For example, both of the other high secure hospitals had reported positive outcomes from using the HOPE(S) model, a human rights-based approach designed to reduce the use of segregation and improve outcomes for patients subject to restrictive practices. The hospital had developed its own approach through the Reducing Restrictive Practice Team, incorporating some elements of the HOPE(S) model. However, during our assessment, we found limitations in how this approach operated, and only a small number of staff had received training in its use. As a result, we were not assured that the benefits of this approach had been fully embedded across the hospital.