The Princess Alexandra Hospital NHS 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

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The evidence showed some shortfalls. The trust had a clear, shared vision and strategy. Whilst the strategy was being refreshed work was required to enhance culture, including transparency around decision making, equality, diversity and inclusion and meaningful engagement.

The PAHT2030 strategy was launched at the beginning of 2021. It was a 10 year strategic roadmap for the hospital with 5 main priorities: ‘transforming our care’, ‘our culture’, ‘digital health’, ‘corporate transformation’, and ‘our hospital’. The strategy was developed to guide the trust through post COVID-19 recovery and aligned with the NHS long term plan. The trust vision remained focused on how it planned delivery of care. ‘To be modern: always using up to date treatments, technology and facilities’. ‘To be integrated: working as one to provide joined up healthcare that always puts patients first’ and ‘ To be outstanding delivering healthcare that our patients deserve and that makes us proud’.

Alongside the PAHT2030 priorities was the corporate objectives ‘patients’, ‘people’, ‘performance’, ‘places’ and ‘pounds’ known as the 5Ps.

The trust had 3 values to work by which was ‘patient at heart, ‘everyday excellence’ and ‘creative collaboration’.

The PAHT2030 strategy had not fully embedded throughout the organisation, and it had not translated consistently from the executive level to the front line. Leaders had informed us that strategic priorities were developed through significant engagement work. This involved many conversation and listening events over a 12 month period as documented in their strategy documentation.

We had limited examples of how partners had been engaged in the development of the trusts strategy in 2021. However, partners including those with established relationships with the trust, gave feedback that they had been involved in ongoing strategic discussions. At the time, partners were satisfied that the trust objectives were aligned to the objectives and priorities within the local system.

We heard mixed responses on the understanding of the trust strategy. Some staff focus groups reported not being sure if PAHT2030 was still going ahead while others demonstrated a clear understanding of the strategy. Staff were not made aware of updates, developments and progress of the strategy. Some of our assessments of services showed positive examples of some of the trust values in action.

Changes to staffing structures adversely affected staff morale. Significant large-scale change had already been delivered within the trust over the last 24 months. There had been a recent restructure within the organisation and a number of job consultations that followed. The executive team acknowledged this had been a difficult process and was hugely unsettling for staff within the organisation. Staff reported negative reflections of the process. During our focus groups staff felt ‘done to’ and were not provided with the rationale behind the decisions that were made. This left feelings of frustration.

We undertook 14 focus groups speaking to around 65 staff. Staff reported that there was a general improvement since the executive leadership had been in place with room for improvement. Staff reported that ongoing job consultations heightened stress levels and reduced morale, they reported communication around this had been poor.

The trust acknowledged that culture needed improvement. Improving the culture was a strategic priority at the trust. Before our inspection we received information from staff of a bullying and toxic culture at a senior level. Whilst this was a relatively small number of staff comparable to the volume of staff employed, this information provided evidence of pockets of practice and behaviours which did not align with the trust’s values.

At the time of the assessment the trust was going through a refresh of their strategy. With a relaunch to take place in April 2026. The trust planned to invest £35.8 million of capital, including £17.7 million of external funding, into estates, digital, the community diagnostic centre at St Margaret’s Hospital, and equipment maintenance. Although the trust initially forecast a capital overspend of £2.7 million, it subsequently confirmed that it remained within its 2025/26 capital allocation. The overall backlog maintenance bill was estimated to be £120 million. As a result, the Princess Alexandra Hospital was in wave 2 of the national New Hospital Programme. The trust informed us that because of delays in the implementation of the New Hospital Programme, and the associated risks to staff welfare and patient safety, its previous strategy had been overtaken. This had led to uncertainty for staff, patients and stakeholders.

The trust board meeting was not fully accessible. The board held its meetings at the main Princess Alexandra Hospital and did not hold it at the different sites which limited how accessible it was to attend. The Trust did not support accessibility by allowing attendance remotely where appropriate. The board meeting was also not recorded and therefore could not be accessed unless you attended in person. Board meetings were also not accessible via online meetings. However, Board meetings included a session to hear from people who use the services and their carers.

Staff told us that senior leaders did not always prioritise the needs or perspectives of their direct reports. Staff told us about how they found their direct teams and local leadership largely accessible and open in their approach. However, above ward managers feedback was generally negative, reporting a lack of support, not being listened to and a lack of appreciation of the issues at hand. Whilst staff knew how to raise concerns staff reported that concerns were not taken seriously. Staff also reported that 1:1 processes felt like a tick box exercise.

The trust had demonstrated limited evidence of effective change to improve staff satisfaction. The most recent NHS staff survey results (published in March 2025) for the trust had a response rate of 49%. Results showed PAHT scored lower than the average for all People Promise Elements. Discrimination, harassment and violence remained above national levels. Potential operational barriers continued to hinder staff access to appraisals and development opportunities. This reflected a stable but stagnant environment where improvement efforts have yet to be translated into meaningful change. Analysis of the staff survey results identified culture and leadership as a key theme. Findings showed that the most significant challenges lay within the ‘we are safe and healthy’ people promise element. This part of the staff survey highlighted that the workforce had been under sustained pressure, their wellbeing concerns had not been addressed and leaders had prioritised attendance over health and safety.

We saw limited evidence of Equality Impact Assessments integration within workforce and service transformation programmes. Policies referenced mandatory Equality Impact Assessments (EIA) for new processes and aligned with the public sector equality duties and Human Rights Act. Post assessment we were provided with evidence that showed that EIAs were used within Urgent and Emergency Care, the cancer programme and the phlebotomy services.

At the time of the assessment, the trust was realigning it’s services, moving from 5 clinical divisions to 3. Senior leaders reported that a refreshed Accountability Framework was due for Board approval in February 2026, to support this change. We reviewed the February 2026 board papers but were unable to verify that the updated Accountability Framework had been presented. Post assessment we was provided with evidence that an updated version of the Accountability Framework had since been developed and was currently pending publication.

Appraisal compliance was low, leaders had not ensured that staff received timely and meaningful performance reviews. Low appraisal rates meant that the trust did not have effective oversight of staff development, performance, and well-being, and many staff were going without the support and feedback needed to carry out their roles safely and confidently. At the People Committee on 26 January 2026, leaders reported that appraisal rates remained low. Compliance stood at 74%, below the trust target of 90%. The trust recorded only a 1% improvement in December 2025. At this point, 200 staff had not received an appraisal, and a further 857 completed appraisals were due to expire by the end of March 2026. The committee discussed using the organisational restructure as an opportunity to reset expectations around appraisal completion. The people team worked alongside managers, focused on improving both appraisal compliance and quality. They strengthened training, provided 1 to 1 support, refreshed the electronic appraisal form, offered workshops, and issued targeted communications to staff and managers. There was evidence of consistent appraisals for Non-Executive Directors.

The trust was continuing to develop a fully embedded approach to reducing health inequalities. Although it acted as the host provider for the West Essex Health and Care Partnership and held a strategic role within the Hertfordshire and West Essex Integrated Care System (ICS), progress remained at an early stage. A board report presented on 18 November 2025 stated that the health inequalities programme was still developing, and the board was asked to approve proposals to strengthen this work. An initial assessment identified 45 ‘do now’ actions, 17 ' to do later’ actions and 22 ‘don't forget’ actions, showing that the programme required sustained focus. A Health Inequality Self-Assessment Tool completed on the 3 November 2025 indicated low overall maturity, with public health capacity rated at 50%, data and insight at 43% and strategic leadership and accountability at 44%. System partnership working scored more strongly and was rated as thriving at 90%. Together this evidence demonstrated early progress but highlighted that the trusts internal capability and leadership arrangements for addressing health inequalities required further development..

Medicines Optimisation (MO) was a strategic priority for the trust and remained embedded in their vision and that of the wider trust. The strategy was currently being refreshed to align with a new vision centred on community collaboration and care closer to home. This strategy successfully integrated with the local Integrated Care System (ICS) to ensure clinical pathways were seamless, even as the trust navigates geographic transitions and leadership changes. A major focus was on workforce transformation, which had already resulted in 12-hour, 7-day pharmacy coverage in frailty units and the expansion of specialist pharmacist roles in complex areas like neurology, gastroenterology and rheumatology.

All board members understood the shared vision, strategy and just culture to consistently drive forward effective change and strategic goals of the trust. We observed the board working in a cohesive and collaborative way to achieve its strategic goals. All non-executive directors carried out their roles and responsibilities with sufficient and robust challenge. This offered aid to the board and ensured focus on strategic delivery.

The trust strategy had a strong focus on patient experience. Patients were often at the centre of conversations for improvement and drive.

The evidence showed some shortfalls. Leaders understood the context in which the service delivered care, treatment and support. Leaders had the skills, knowledge, experience and credibility to lead effectively and did so with integrity, openness and honesty. They were visible and accessible. Work was required to enhance governance and actively promote an inclusive and positive culture.

Leaders generally had the skills, knowledge and experience to perform their roles. We observed the trust board, attended several quality committees and reviewed executive meeting minutes. In all meetings, leaders acted with integrity, credibility, effectiveness and kindness. They demonstrated a clear passion for delivering services that met the needs of their communities. We observed that the board worked cohesively, with appropriate levels of constructive challenge during meetings, including from non-executive directors.

The trust board comprised 8 Executives and 5 non-executive directors (NEDs) including the chair, and 3 Associate NEDs. Since the last inspection in 2021 there had been significant changes to the board, including the Chair, Interim Chief Nurse, Medical Director, Chief Operating Officer, Chief People Officer, Chief Financial and Infrastructure Officer and Deputy Chief Executive and a Chief Executive Officer.

Stakeholders and partners told us that the board had the experience, capability and personal values required to lead the organisation. The leadership team was described as open, honest and transparent. Stakeholders and partners had visible faith within the trust and across the wider healthcare system. Staff also took leading roles in system wide initiatives and leaders had established strong and professional working relationships with partners.

Board meetings often included a patient story, with patients invited to share their experience of care. People who use services, non-executive directors and stakeholders consistently described trust leaders as approachable.

Leaders were visible across services and staff describe them as accessible and available. Leaders told us they undertook regular visits to frontline areas, including both non-executive directors and executive directors. These visits improved leadership visibility and engaged triangulation of information received through governance systems, particularly regarding staff experience. Non-executive directors also visited services relevant to the committees they chaired. These visits were both scheduled and unannounced. However, this was only reflected at the main site in Harlow and was reported to be limited to the community hospitals in Bishop Stortford and St Margarets and the Kao building in Harlow. We were told there was limited senior leadership visibility during night hours, raising concerns that executives may not have first-hand understanding of challenges arising outside normal working hours.

Succession planning was well considered, and leaders provided opportunities for staff to act up into senior roles. The trust commissioned an external organisation development consultant to coach and develop the newly formed executive team. It also introduced a board development programme to review board members skills and strengthen succession planning at senior level.

The trust did not actively support diverse communication needs at board level. Executive board meetings were only accessible in person and virtual attendance was not facilitated for either public or private sessions. As a result executive boards were not fully accessible. Board papers were circulated in advance and were available online following meetings. Board meetings were held across different sites to support the attendance, but only two of the four possible locations were used.

The trust could not demonstrate that all senior leaders were safe, suitable and appropriately vetted for their roles. We reviewed a sample of seven personnel files for executive and non-executive directors. Fit and Proper Person checks were in place, but we found inconsistencies. Some files lacked references and some executive leaders had not signed required declaration forms. The trust had also not recorded Disclosure and Barring Service (DBS) checks consistently or accurately. This meant that the trust could not demonstrate consistent compliance with Fit and Proper Persons requirements or adherence to its own policy.

Board development activities that would deliver sustained improvements in leadership effectiveness and governance maturity were not yet embedded. The trust had commissioned external support to strengthen leadership capability and develop the newly formed executive and divisional teams. A Board development programme had been initiated with work planned on skills, behaviours and culture. However, at the time of the assessment the development plan lacked clear timelines, measurable outcomes and defined links to improving the Board's oversight of quality, risk and patient safety. Post assessment the trust provided evidence that the Board development programme had been completed with a roll out in March 2026.

The evidence showed some shortfalls. People could feel that they could speak up, however they did not feel that their voice was heard.

The Freedom To Speak Up (FTSU) governance required strengthening and the process left staff using the service unprotected. The trust completed an FTSU self-assessment in August 2025 which was updated in October 2025. The assessment identified several areas requiring formalisation, including improved training coverage, strengthened governance pathways, and clearer evidence of impact before the service could reach further maturity.

The FTSU guardian met with the Director of Clinical Quality and Governance to discuss patient safety concerns raised through FTSU. However, this arrangement was ad hoc and lacked a formal governance pathway to ensure timely escalation, oversight and learning.

Awareness of FTSU was promoted at corporate induction, preceptorship programmes, junior doctor induction and staff network meetings. Some staff told us they were aware of the FTSU process and knew to contact the guardian. Others reported that although they felt able to raise concerns, the process felt like a tick box exercise due to the limited escalation and visible action taken.

The July 2025 NHS People Pulse Survey showed that 77.1% of staff had spoken about concerns in the previous 12 months, with 44.4% of these concerns relating to workplace culture. Most staff, 82.5% said they could speak to a line manager or supervisor, while 25.9% said they would speak to the FTSU guardian. However, 37% of staff reported a negative experience after speaking up, and almost half described poor behaviours following the raising of concerns. During focus groups staff described supported colleagues who had raised concerns and were experiencing difficulties as a result. It was also highlighted that staff on visas were feeling reluctant to speak up because they were worried about the potential impact on their own or their family’s visa status.

The trust did not have a dedicated FTSU mailbox. This meant emails sent directly to the lead could go unchecked for several days, reducing accessibility for staff wishing to raise concerns. However, post assessment we were told the lead guardian identified other guardians in her out of office automated response email when out of the office.

All FTSU cases were managed on an individual basis in line with National Guardian’s Office (NGO) principles and guidelines. However, we were unable to ascertain how fairness was implemented or measured because the Trust had not formalised its processes for assuring fairness in investigations of judgement, addressing bias in case handling, or evaluating outcomes. Although the Freedom to Speak Up policy set out a route for investigating allegations of detriment, the Trust used feedback forms to record reports of detriment and could not demonstrate a structured approach to tracking investigations, monitoring outcomes, or evidencing actions taken. This reported to the board in February 2026.

All FTSU guardians had completed National Guardians Office training. Staff were encouraged to undertake online ‘speak up’ training, although this was not mandatory. Managers were required to complete the ‘listen up’ module and senior leaders and board members were required to complete ‘follow-up’ training. However, the January 2026 FTSU report presented to the people committee stated that FTSU training compliance was not reported. The committee recommended developing a reporting process to strengthen assurance.

The FTSU lead was knowledgeable about the themes and trends emerging from cases and was able to articulate key cultural issues affecting staff. The board received an annual report on FTSU activity. The report demonstrated that administrative and clerical staff used the FTSU process most frequently. The latest data covering July 2024 to June 2025 show that 167 cases had been raised. This suggested that some staff felt safe to speak up which aligned with feedback from our focus groups. 1 case involved concerns about disadvantages or demeaning treatment as a result of speaking up. 9% of cases were raised anonymously. 48% of cases included concerns about inappropriate attitudes or behaviours.

From quarter 3, 2024/2025 the number of cases presented to the FTSU guardian decreased each quarter reducing from 61 to 37 cases by quarter 1, 2025-2026. The trust explained that the surge was recorded in November 2024 which was in line with the implementation of their new electronic patient health record, and changes in perceived working expectations.

The FTSU policy was in date, aligned with national guidance, and included an Equality Impact Assessment completed in August 2025 by the FTSU lead.

Leaders promoted a positive medication safety culture by encouraging open incident reporting and using data to reduce harm. The medication safety strategy focused on an open and honest culture by encouraging higher incident reporting rates while reducing the proportion of incidents that caused actual harm. The trust tracked this performance monthly through statistical charts and presented the findings to the Patient Safety Group to assess the impact of specific interventions, such as communication campaigns and the introduction of dedicated medication safety link nurses on every ward.

Post assessment, the trust provided evidence demonstrating that its Professional Nurse Advocate (PNA) and Professional Midwifery Advocate (PMA) service supported staff wellbeing, professional development and quality improvement alongside the FTSU service. Between November 2025 and February 2026, the service delivered 185 restorative clinical supervision sessions to 363 staff members and supported 113 career progression conversations involving 162 staff members.

The trust had appointed a Freedom To Speak Up (FTSU) Guardian, who carried out their role alongside their position within the Quality Improvement Team. The FTSU Lead Guardian works 18.75 hours per week. The guardian told us they had protected time for both roles, spending one day a week at the main site in Harlow and one day at the Business Park, also in Harlow.

The board had an executive lead for FTSU, which at the time of the inspection was the Chief People Officer. The trust had the appropriate diversity numbers of Freedom To Speak Up personnel in place to support staff. The FTSU guardian was supported by 5 additional guardians and 33 ambassadors. The FTSU report for quarter 3 recorded the ambassador profiles as 14 White, 13 Asian, 5 Black and one undeclared. 28 ambassadors were female and 5 were male. The FTSU lead was aware that the original group of guardians lacked diversity, consisting mainly of 5 White females, and actively recruited a more diverse cohort. This resulted in a group that was more representative of the trust workforce, including nurses and

The evidence showed significant shortfalls. The service did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There were mixed opinions regarding the trusts culture and leaders and the way they were actively engaging in reviewing and shaping the organisation culture in the context of Equality, Diversity and Inclusion (EDI). This was despite the trust having an EDI strategy 2023-2030 ‘Making The Princess Alexandra Hospital NHS Trust (PAHT) a truly inclusive employer and health service provider for our diverse people, patients and local communities’.

Staff networks were in their infancy. During our focus groups staff felt that EDI initiatives were under developed and lacking senior leadership support. The trust had 3 staff equality networks; Race Equality and Cultural Heritage (REACH), Disability and Wellbeing Network (DAWN) and Alex Pride which was the LGBTQ+ staff network. During our focus groups staff reported that there had been visible executive sponsorship of the networks and positive responsiveness when major concerns were raised, including work on community safety. They valued the trust commitment to anti racism initiatives and noted good links between clinical teams and the networks. However, staff reported inconsistent support for EDI, limited protected time and a lack of involvement in EDI strategy and decision making. Staff described variable leadership behaviours, insufficient education on discrimination and microaggressions, and limited spaces to raise concerns. They also highlighted gaps in procedures, a single point of failure for the EDI lead and inconsistent engagement from senior leaders.

Numerous compliance actions for the trusts Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) EDI delivery plan remained incomplete and continued to be RAG rated Amber. These included the review of the recruitment inclusion specialist role, intended to strengthen challenge and reporting of bias in recruitment processes, which had not been delivered by the March 2025 deadline. The trust had also not completed its planned culture-change work to set behavioural standards to address bullying and harassment or to progress related staff-network initiatives, which were due in March 2025. Mandatory Equality, Diversity and Inclusion training was implemented across the trust, with compliance at 96%, exceeding the 90% target. Enhanced disability awareness training introduced in September 2025 had been delayed, the trust recognised this as a priority. This was reflected in an updated WRES and WDES action plan. The trust had not established the planned system for annual monitoring and recording of bullying, harassment and abuse incidents between staff, which was due for completion February 2025. In addition, the proposed business disability forum audit of polices, practice and processes to improve the experience of staff with disabilities had not been undertaken by the March 2025 deadline.

Analysis of the 2024 NHS WRES and WDES metrics carried out between October and November 2024 and published in March 2025, showed that Black and Minority Ethnic staff with long-term conditions had experienced poorer treatment, fewer progression opportunities and gaps in support and inclusion across the trust.

NHS staff survey 2024 results showed that 13.16% of staff had experienced discrimination on the grounds of gender. This was a 2.65% decline from 2023.

The trust maintained an EDI strategy and a governance timetable supported by an EDI delivery plan for 2025-2026. An EDI Steering Group provided forward plans, structured escalation routes and annual reporting. Equality Diversity System 2 (EDS2), WRES, WDES and pay gap reports were completed and approved by the board. Governance arrangements aligned with the NHS England EDI improvement plant and the East of England anti racism strategy.

However, the EDI strategy read as generic and open ended and EDS2 required further formalisation of actions particularly in workforce wellbeing and inclusive leadership. Data quality remained inconsistent with high unknown rates for several protected characteristics on the Electronic Staff Record (ESR). The trust needed stronger EDI performance indicators, clearer monitoring arrangements and a defined publication schedule.

The trust did not have focused development pipelines for women, disabled staff and global majority staff. Global majority is a term used to describe people who are racially or ethnically minoritised in Western context but who collectively make up the majority of the worlds population. The trust had not achieved proportionate representation of global majority, disabled and female staff at senior bands. Global majority staff remained under represented in senior non clinical roles. In the October 2025 public trust board papers, bands 8C and above showed persistent discrimination experienced by global majority staff. Bullying and harassment indicators remained above national averages for both global majority staff and white staff, although they had shown gradual improvement. Recruitment data continued to show relative likelihood disparities, with white candidates more likely to be appointed. The trust had not reached a 1 to 1 short listing to appointment ratio; progression bottlenecks were evident at band 6 and 7 for global majority staff. However, there was strong global majority representation in clinical roles particularly with the medical and dental workforce.

The trust's gender pay gap remained significantly influenced by senior role distribution and the composition of medical workforce. The disability pay gap stood at a mean 9%, however, the accuracy was limited by low declaration rates. The overall ethnicity pay gap favoured global majority staff due to weighting in medical roles however, higher band senior roles remained disproportionately white. This suggests structural barriers in recruitment, development and progression. Incomplete demographic data continued to undermine the trust's ability to diagnose inequality and target remedial action.

Across freedom to speak up WRES, WDES and staff survey datasets the trust continued to see elevated concerns regarding behaviours, microaggressions, exclusion, and inconsistent grievance outcomes. Results also showed that managerial support culture and leadership behaviours varied by division, indicating inconsistent supervisory practice. This was also reflected in our focus groups. The trust had introduced a zero-tolerance campaign at the time of our assessment however; it was too early to evidence sustained impact.

Disciplinary cases between January 2024 and December 2025 identified 26 cases during this period. Of these, 73% involved staff from white backgrounds, 19.2% from Asian backgrounds, and 3.8% from black backgrounds. Analysis of Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) metrics within the NHS Staff Survey highlighted that Black and Minority Ethnic staff and staff with long-term conditions experience worse treatment, limited progression opportunities and gaps in support and inclusion across the trust.

Succession planning did not consistently translate into measurable outcomes. The trust had begun to roll out a debiased recruitment toolkit and was reviewing a recruitment inclusion specialist role. It engaged with external networks, including regional leadership and inclusion partners.

However, accountability structures were clear, with an executive lead, a non-executive Freedom To Speak Up lead, and an active EDI steering group. The board oversaw WRES, WDES, pay gap and FTSU reporting. Though, board level visibility needed to increase around bullying and harassment, psychological safety, lived experience of protected groups and the measurable impact of EDI interventions. At executive level the EDI portfolio did not demonstrate a full grip and oversight. Leaders focused on language around belonging rather than explicitly naming racism or discrimination. They did not clearly articulate the overarching EDI strategy and approach. Focus had shifted from staff on staff behaviours to patient on staff issues following a 12 month initiative, however, the timeframe may not have been sufficient to embed sustained cultural change. The executive lead acknowledged challenges for international recruited colleagues but referred frequently to the head of EDI which suggested the agenda was not consistently led at executive level. The executive team maintained a close relationship with the CEO and all executives held EDI objectives. The EDI strategy although was present it remained generic and required greater specificity in milestones and measurements.

The evidence showed some shortfalls. The trust did not always have clear responsibilities, systems of accountability and good governance.

There were systems and processes in place for identifying, managing and monitoring risk. This included a risk management strategy, Board Committee structure, a risk management group and trust-wide tools such as the corporate risk register and Board Assurance Framework. Incidents were monitored through established reporting systems. Each division and corporate department maintained a regularly reviewed risk register. Once approved locally, high-scoring risks were escalated to the risk management group. We observed appropriate challenge and discussion when considering risk for inclusion on the corporate risk register.

Despite senior leaders having a clear understanding of the organisations top 3 risks; estates, workforce and operational performance. The estates risk only partially articulated the impact of estate failures on capacity, staff engagement and safety of care. While patient experience, staff morale and infrastructure safety risks were acknowledged, the operational and patient outcome consequences were not fully developed, and the controls and assurance did not clearly demonstrate how the Board would assess the effectiveness of risk mitigation.

The 2025/2026 Board Assurance Framework (BAF) was presented to board in April 2026.The BAF did not present risks, controls or assurances in a way that was easy to follow, and it required improvement to focus on the key controls and assurance needed for the trust priority risks. Although the BAF described the main risks and objectives, the controls, assurances and actions were not articulated clearly enough. It was not obvious which actions were most critical, to close assurance gaps and reach the target risk levels. The staff engagement and morale risk did not assess the underlying causes, despite long standing cultural concerns (evident in repeated low staff survey results). The BAF did not reference Freedom To Speak Up issues or demonstrate how leaders responded to cultural risks. The BAF lacked alignment with the trusts partnership strategy and the work underway through the New Hospital Programme to review service models and future estate use. As a result, several principle risks required review to ensure they line with the current strategic objectives. It was not clear how the board assured itself or managed significant risks related to culture or estates.

The inconsistency in risk descriptions, controls, mitigations and assurances meant the board could not be fully assured that risks were understood, monitored or effectively controlled across the organisation. Strengthening the risk register and it's link with BAF was necessary to support safe, well led governance. Evidence showed that many risks on the corporate risk register lacked sufficient detail, and some teams could not describe the equipment or issues reference in their own entries. Assurances and mitigations were often recorded inaccurately, and several risks did not align with the controls said to be in place. Key information such as the date each risk was added, the role of the risk owner, and the links to the BAF were missing or unclear. We also found inconsistent understanding of divisional risks, a lack of alignment between risks and actions, and significant variation between divisions and how controls and assurances were described. These weaknesses meant the board could not be confident that the organisation had a coherent, reliable or well understood system for identifying and managing operational risks. Following the assessment, the trust provided evidence that it maintained a live electronic risk register. Risks included documented opening, review, lifecycle and closure dates enabling effective oversight and management.

Senior leaders reported that a refreshed Accountability Framework was due for Board approval in February 2026, to support this change. We reviewed the February 2026 board papers but were unable to verify that the updated Accountability Framework had been presented. Post assessment we were provided with evidence that an updated version of the Accountability Framework had since been developed and was currently pending publication.

The trust experienced sustained staffing risk. 17% of staff reported feeling negatively affected due to being short staffed. Between June and November 2025 there was 328 reported incidents for staff shortages; 94.82% of which involved a lack of suitably trained or skilled staff. Trust data showed that some wards had very high vacancy, sickness, and turnover rates. For example, Nightingale Ward had over 70% of jobs unfilled, and some elderly care wards had sickness above 9% and turnover above 20%. This meant leaders had not fully managed these workforce problems, and staffing needed to improve to keep services stable.

The trust did not meet the national 62 day cancer treatment standard or the 28 day Faster Diagnosis Standard during 2024/25. Cancer performance declined following implementation of the electronic patient record system in November 2024 and improved thereafter. Data from December 2025 showed, performance against the 28 day standard was 77.4% and performance against the 62 day standard was 67.5%.

Significant delays in the incident investigation process, resulted in limited timely learning and reduced assurance that risks have been addressed promptly. The trust was not meeting the 60 day KPI for patient safety incident investigations out lined in their Patient Safety Incident Response Plan (PSIRP). Closed investigations from August 2024 to February 2025 took an average of 121 working days to complete, and open investigations had already been active for an average of 185 working days as of 29 January 2026. Post assessment we were told that 2 of these investigations were undertaken externally outside the scope of control of PAHT.

The trust was not consistently responding to complaints with the agreed time frames set out in policy. In 2024/2025 the trust received 318 complaints which was an increase of 172 (84%) complaints from 2023/2024. Of the 226 complaints closed 66 complaints were not upheld, 149 partially upheld and 11 fully upheld. The trust acknowledged the increase in complaints due to a lack of prompt action in actioning PALS complaints which in turn escalated complaints to formal complaints. The trust had processes to respond to complaints from people using the service. We met with the trusts complaints team and reviewed 5 complaints. Out of the 5 complaints,2 had breached the trust’s acknowledgment and resolution timeframes. However, the letters were easy to read, avoided jargon, and maintained a respectful, empathetic, and professional tone, acknowledging the complainants’ concerns and demonstrating an understanding of their distress. Although these actions were not time bound, the responses demonstrated that the trust was committed to making improvements. All response letters were reviewed and signed off by the chief executive.

The trust had a stable Summary Hospital-level Mortality Indicator (SHMI). The SHMI is the ratio between the actual number of patients who died following hospitalisation at the trust and the number what would be expected to die. The trust remained comparable to peers and were not statistically significant regionally or nationally. However, the standardised mortality ratio was higher than expected in November 2024. This was linked to the introduction of the new hospital standardised mortality ratio and the recent implementation of the new electronic patient record. Coding errors associated with the transition to the new system led to inaccurate data capture, resulting in a falsely elevated mortality rate.

The trust’s ability to triangulate activity, workforce and financial information effectively was limited by their electronic patient record. Clinical data quality remained a significant and ongoing concern. The Trust told us that the implementation of the new electronic patient record in November 2024 resulted in under-reporting of activity and wider data reliability issues, including the use of workarounds. A recovery plan was still being developed at the time of our assessment (15 months post implementation of the electronic patient record system), and the associated risk remained on the Board Assurance Framework. The Trust also told us that its integrated performance report (IPR) was currently being refreshed to strengthen the quality and presentation of performance information.

The Board had not yet undertaken a discussion to establish its financial risk appetite for 2026/2027 or consider the balance between financial, operational and workforce risks.

The trust did not operate a stroke unit, which meant it could not provide an internal stroke pathway for patients admitted with suspected stroke. When these patients required specialist care, leaders relied on external providers which were frequently at full capacity. This created delays, increased operational risks and risks to patients, which leaders frequently reviewed. Although this challenge remained largely outside the trust’s direct control, leaders continue to escalate it and engage with system partners. They anticipated that joining the wider Essex footprint would strengthen regional collaboration and improve access to specialist services in the future.

The trust governance manual set out the organisation’s governance structure, decision-making processes and accountability arrangements, providing a single reference point for how the trust was governed.

Leaders cited estate related challenges as the primary cause of delays in responding to the fire risk assessment, which identified risks in July 2024. However, leaders had not demonstrated the effectiveness of the mitigating actions that had already been implemented to address those risks. The assessment identified a significant to intolerable level of fire risk. While the likelihood of a fire was assessed as average, fire precautions provided a below average level of protection and the potential consequences of a fire were significant. The trust had governance processes in place to oversee fire safety risks and leaders monitored these through committees and the estate risk register. Action plans were developed and improvement work was underway, including fire door replacement, fire stopping works and fire alarm upgrades. Evidence from the Performance and Finance report November 2025 showed that key actions remained in progress 16 months after the fire risk assessment as part of a phased improvement programme. However, during our onsite assessments in November 2025, we found a blocked fire exit and fire doors being held open. These findings demonstrated that fire safety risks remained present and that fire safety controls were not consistently followed in practise.

The trust identified 120 staff whose DBS records were not visible on the central trust system representing. Most cases related to historic appointments or overseas recruits whose UK checks were being completed. All roles were risk assessed, patient facing staff were prioritised and interim safeguards were applied. HR coordinated the process of daily tracking, and all outstanding checks were scheduled for completion by the end of January 2026. Professional registration data was circulated and emailed monthly to all divisions. This included details of registration membership body and expiry dates.

Exception reports from October 2025 to December 2025 showed an increase in the number of senior doctors, from Specialty Trainee year 1 doctors to Specialty Trainee year 7 doctors, submitting reports. The Guardian of Safe Working's quarterly report identified 76 exception reports in quarter 2, many of which related to working hours. Senior doctors continued to submit exception reports, reflecting a sustained trend from the previous quarter. First Year doctors submitted the highest number with 39 reports, followed by Specialty Trainee year 1 to 7 doctors with 37 reports. For the first time, senior doctors reported at similar levels to FY doctors which indicated that exception reporting had become more normalised across grades. Medicine remained the specialty with the highest number of exception reports. The increase in trauma and orthopaedics resulted from staff working beyond contacted hours at weekends and resulted in a work schedule review. The current Guardian of Safe Working had stepped down from their role; however, no successor had been appointed.

Performance was regularly reviewed and discussed at board meetings. Performance reports were of good quality and used statistical data to identified areas of high performance and shortfalls The trust monitored its position through Key Performance Indicators (KPIs). This was through a monthly integrated performance report which was reviewed across relevant sub-committees.

Diagnostic performance at the trust was impacted by an increase in demand. The trust had opened the Community diagnostic Centre at the St Margaret's site and expanded diagnostic capacity to improve access to services. At the time of the CQC inspection, diagnostic performance had improved, with the trust achieving 64.2% against the diagnostic waiting times and activity, [DM01] standard. Performance for computed tomography [CT] and magnetic resonance imaging [MRI] was stronger, achieving 85.6% and 80.4%, respectively.

The trust improved Emergency Department (ED) four-hour performance from 62.9% in May 2025 to 75.2% in October 2025 and maintained performance at 75.1% at the end of the CQC inspection period in January 2026. Performance was 80.7% in May 2026. Contributing factors included the implementation of a surge plan, changes to front-door streaming arrangements, development of frailty and same-day emergency care services, closer working with community partners, and increased executive oversight of performance.

The trust also improved Referral to Treatment (RTT) performance from 48.8% in April 2025 to 56.0% in January 2026 and 66.8% in May 2026. Contributing factors included demand and capacity reviews, pathway redesign, weekly executive-led waiting list oversight, collaboration with community and primary care partners, and increased focus on performance across clinical and operational teams.

During 2024/2025 the trust no longer had patients waiting over 78 weeks. By March 2025 the trust reduced the 65 week waiting list from 583 patients to 17 patients.

The Board was told that the trust had met all required standards for the 2024/2025 Data Security and Protection Toolkit. This showed the trust handled patient organisational data safely and met national cyber and information-governance requirements. The internal audit gave the trust a high confidence ratings, and the annual external audit provided further assurance that information-governance processes were working well.

There were 5 operational directorates which were merging into 3. Each directorate was led by a divisional director and supported by medical and nursing leadership. Each directorate had (monthly) meetings.

There were 8 committees that fed up to board. These were Audit Committee, Charitable Funds Committee, Performance and Finance Committee, Quality and Safety Committee, Remuneration and Nomination Committee, People Committee, Health and Care Partnership Board and Executive Board. The board met 6 times a year and the subcommittees fed up into these meetings. Key risks and updates were shared in a report from each committee to the board. The non-executive directors (NEDs) were aligned to the committees and also attended meetings which they did not chair to get a broader understanding of the trust.

Executive members were responsible for their own portfolio.

There was a clear organisational framework guiding how services should develop, Improve and operate. The trust had established strategies for communications, dementia and delirium, a quality, diversity and inclusion, information and communication technology, mental health, nursing, midwifery and allied health professionals, integration, safeguarding, therapies, an integrated delivery plan, people comment and quality and patient safety. These strategies encouraged and line meant to the trust's overarching vision.

There was a strong emphasis on Emergency Preparedness Resilience and Response (EPPR) and business continuity. The trust took a hands on approach to EPPR, tested plans monthly and regularly validated major incident arrangements. There was a proactive cycle of testing ensuring the trust remained prepared for unexpected events whilst maintaining critical services under pressure.

Pharmacy leaders managed high level risks such as staffing and ageing infrastructure through the central risk register and reported via divisional and trust level forums. Despite financial constraints, the pharmacy department modernised its aseptic unit and robotic dispensing, although a business case remained pending for essential refurbishments on the lower ground floor.

Pharmacy leaders described a key strategic priority as the expansion of pharmacist led TTA prescribing. By taking responsibility for the discharge process on several specialty wards, the pharmacy team aimed to improve the accuracy of information sent to GPs and speed up patient discharge. The department maintained a strong presence in assessment areas, but the emergency department was limited with no dedicated pharmacy presence. This was recorded on the risk register as a priority for future funding to strengthen medicines reconciliation and antibiotic stewardship at the point of admission.

Safety remained a collaborative focus for pharmacy leaders. The team managed the signoff process for Patient Group Directions (PGDs), provided annual homecare reports to the Board, and implemented national patient safety alerts effectively.

The pharmacy workforce strategy set out clear routes for progression and retention, with defined career pathways for pharmacists (Band 6 to 8A) and technicians (Bands 4 to 6), and plans to extend this to pharmacy assistants. The department achieved notable success in newer areas such as the frailty and assessment units. However, legacy ward services continued to face rising demand that outpaced available staffing.

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

The trust build strong rapport with the local mental health provider and invited appropriate senior leaders to attend board meetings. This demonstrated effective partnership working and collaborative decision making.

The trust engaged with people and communities to seek their views and feedback. Leaders at the trust board were invested and active in building positive relationships with partners and communities. The trust had executive leader representation as members of the Integrated Care Board, various working groups and specific meetings to represent the trust within the community.

The trust patient panel was well established, accredited, and actively embedded in the organisation governance framework. The panel ensured that the patient voice informed decision making, service design, and quality improvement. Members engaged regularly with senior leaders, attended public board meetings, carried out ward visits, reviewed patient surveys, and contributed to key governance processes, including recruitment and freedom to speak up activity. The panel had an up-to-date terms of reference that clearly set out its purpose, membership, responsibilities, and roots of escalation. They produced a new report which summarised its activities and provided assurance to the community about it’s impact over the previous 12 months.

The panel took active steps to improve diversity and broaden representation. Members conducted outreach in local places of worship and community spaces, including shopping centres, to encourage wider participation. The panel also engaged younger people through organised educational visits for school children to learn about hospital services.

The panel worked with key stakeholders of the trust to improve accessibility to care. The panel supported system level work with Integrated Care Boards to improve accessibility in areas of deprivation and promoted access to primary and secondary care. Members contributed to trust initiatives to improve support for patients with disabilities. They encouraged the use of plain English and translated information to improve communication with patients whose first language was not English.

The panel participated in system wide engagement, attending local partner meetings and NHS confederation events. They collaborated with local universities to support youth engagement and explored learning from other healthcare systems including in Scotland and Sweden. Members supported community initiatives, such as work with the Royal British Legion. They completed risk assessment and safeguarding checks for volunteers and visiting children, demonstrating a strong commitment to safety and good governance.

Panel members reported feeling listened to by the current board and described a strong, positive relationship with the CEO. They contrasted this with the previous leadership commenting improved openness transparency and co-production. The panel said the main cultural challenge for the trust remained a long standing ‘we have always done it this way’ mindset. However, they reported that current leaders engaged constructively with them to address cultural and operational issues.

The patient panel received significant national recognition for its contribution to patient experience in community engagement. Achievements included the Queens award for voluntary service, the unsung hero award 2024, and a British Empire medal. The panel also included the trust first volunteers speak up ambassador.

The trust worked collaboratively with their stakeholders. The trust was a member of the West Essex Health and Care Partnership Board with the trusts CEO chairing the meeting. It worked with commissioning organisations including primary care networks, to help improve health outcomes in West Essex and parts of East and North Hertfordshire. The partnership aimed to reduce health inequalities and prevent poor health. There were 3 priorities in place supported by a 3 year Integrated Delivery Plan (IDT). The IDT mapped to the priorities through transformation programmes and collaborative working. The IDT focused on: addressing health inequalities, proactive care for the frail population, improving access to urgent care services, reducing waiting times for planned care, improving outcomes for children and young people and efficient use of resources. Some of which align to the NHS Core20PLUS5 initiatives. Core20PLUS5 is a national NHS England approach to support the reduction of health inequalities at both national and system level.

The trust analysed patient safety incident data against the NHScore20plus5 criteria to determine whether patient with a high BMI, those living in deprivation, members of the deaf community, people with learning difficulties, African men or Black women were disproportionately affected. The trust was in the process of undertaking a review of their clinical strategy to assess how each service addressed health inequalities.

The trust had worked closely with community partners, educational institutions and employability services to develop pathways into healthcare careers. The trust signed a Memorandum of Understanding with Harlow College, agreeing to co-develop a Health and Science Academy to provide direct routes into healthcare careers.

Stakeholders reported an open approach and collaborative working to improve patient outcomes. It was also noted that the trust had established and strengthened their relationships with primary care to improve partnership working. Stakeholder feedback suggested improvements to relationships had improved over the last 12 months with primary care providers. The trust and primary care colleagues met regularly through monthly meetings and clinical and professional leadership forums, clinical directors and clinical leaders discussed shared priorities such as the transition to the new electronic patient record and challenges around discharge communication. These meetings created a consistent space for collaborative problem solving and an agreement on a shared way forward. Primary care providers reported knowing who to contact when needed and clear communication channels.

Feedback from local Healthwatch organisations generally noted a positive relationship with leaders at the trust including the CEO and the Patient Engagement team. Reporting regular engagements and direct routes into shared learning.

The trust worked with the local Integrated Care Board (ICB) and local council to relocate diagnostic services from the hospital into the community. The trust had agreed plans to relocate move other suitable services out of the hospital and into accessible community settings.

The pharmacy department maintained a strong patient public engagement through the involvement of a patient panel representative on the medical optimization group. This partnership provided a direct feedback loop and allowed patients to challenge technical language, suggest priorities, and contribute to discussions. Governance of controlled drugs was strengthened through dedicated roles and structured reporting. The appointment of a lead CD Technician improved day-to-day oversight. ADIOS reporting helped identify trends and potential diversion risks. The team linked with the Controlled Drugs Local Intelligent Network every three months. Internally, they collected weekly nurse led CD checks from the wards. These findings were summarised in annual report to the trust Board, which kept CD safety and compliance as a board level priority.

In September 2025, NHS England had moved PAHT into NHS Oversight Framework (NOF) segment 4. In the NOF segment 4 signifies an NHS trust facing the most significant challenges, with a broad range of issues across performance, financial health and operations requiring intensive support from the National Recovery Support Programme to improve and achieve sustainable recovery. PAHT ranked 119 out of 134 trusts for Quarter 2, 2025-2026 improving slighting from its position of 120. This placed the trust withing the bottom 15% of trusts nationally based on all NHS combined performance metrics.

Post assessment PAHT was in segment 3 of the NHS National Oversight Framework (NOF). Segment 3 indicates a provider needs increased NHSE oversight and targeted improvement support, with closer monitoring of performance and potential intervention in areas of concern. In quarter 1, 2026/2027 league table for NHS performance, PAHT was ranked 85 out of 134 acute trusts in England.

The trust access policy was currently expired but was under review and going to be the trust's internal governance process. The trajectory was for the end of March 2026 for ratification and publishing.

The evidence showed some shortfalls. The trust did not always focus on continuous learning, innovation and improvement across the organisation and local system.

The trust had done little in the way of learning or improving from previous surveys.The trust was the worst performing trust nationally, as it was the only trust whose combines results for every benchmarked question in the 2024 adult in-patient survey were rated ‘much worse than expected’. Its ‘much worse’ status applied to both medical and surgical respondents. This was the fourth year in a row that the trust had benchmarked overall as ‘worse’ or ‘much worse’.

The trust had undertaken a number of quality improvement initiatives during the previous 12 months and there was evidence that learning from these projects had been captured and documented. However, we were not assured that learning was being systematically disseminated and embedded across the organisation. During our assessment, we identified examples of good practise and adherence to national guidance alongside evidence of a never event occurring within the same five-day period within theatres. This demonstrated variation in consistent application of learning and highlighted that improvements were not yet reliably embedded across all areas of the Trust.

Staff had begun to adopt the principles of learning from incidents through PSIRF, and we saw increasing use of the correct language and methodology. However, this remained at an early stage of maturity. Leaders recognised these gaps and had introduced initiatives to build improvement capability, including the Chief Nurse Fellowship. This programme gave clinicians dedicated time each month to undertake structured QI projects focused on frontline improvement. Post assessment we were told The Quality Improvement Team at Princess Alexandra NHS Trust provided a wide range of training programmes tailored to varying levels of experience. These included a Quality Improvement Induction for all managers (457 trained), alongside Delivering Projects (321 trained) and Delivering Change (706 trained). For more advanced development, 247 staff had completed Quality Improvement Fundamentals (Parts 1 and 2), while a smaller group of 10 achieved Quality Improvement Accreditation. Additionally, the recently introduced Improvement Leaders Programme was supporting 38 staff to further strengthen their leadership capability in quality improvement. The trust had undertaken a number of quality improvement initiatives during the previous 12 months and there was evidence that learning from these projects had been captured and documented. However, we were not assured that learning was being systematically disseminated and embedded across the organisation. During our assessment, we identified examples of good practise and adherence to national guidance alongside evidence of a never event occurring within the same five-day period within theatres. This demonstrated variation in consistent application of learning and highlighted that improvements were not yet reliably embedded across all areas of the Trust.

Leaders maintained an active research and audit programme and demonstrated commitment to quality improvement, however delays in updated the research strategy, limitations in research infrastructure and overdue audit reporting indicated that strategic oversight and capacity planning required strengthening. The trust had 57 open studies during 2024/ 25. Of these, 39 were actively recruiting, including 3 commercial and 37 academic studies. 14 studies were closed to recruitment but remained in follow-up. The research team worked from a limited space at the trust site. This space had become increasingly crowded due to the number of studies and requirement storage for trial specific equipment and kits. The research, development and innovation strategy, last ratified in April 2023, required updating which had been delayed due to changes in departmentally leadership. Their strategy review was now a priority so it could be aligned with the trusts revised to strategic direction. The research team continued to provide quarterly activity reports to divisions, including recruitment data, pipeline studies and key achievements. During 2024/ 2025, the trust recruited 712 participants into NIHR portfolio studies. No recruitment target had been set by the North Thames Clinical Research Network or the East of England Regional Research Delivery Network for the period.

During 2024/2025 the trust participated in 91% of the national clinical audits for which it was eligible, and 86 local audits. Over 20% of local audits had reports overdue. The trust had structures for undertaking audits and in some areas, acted on findings. However, action planning, oversight, and the sharing of learning were not consistently effective. This resulted in repeated findings, limited evidence of sustained improvement and reduced assurance that audit outcomes were systematically translated into timely improvements.

The trust was working towards accreditation in anaesthesia and endoscopy. It held established accreditation across several services, including maternity, neonatal care, blood sciences, cellular pathology, microbiology and occupational health. The trust had 7 accreditations and was working towards 2 more.

The trust had inconsistent levels of mandatory training, which meant staff did not always have the required knowledge, to deliver care safely and in line with national expectations. The service demonstrated 89.27% overall performance in statutory and mandatory training compliance. The highest level of compliance was observed in the values and behaviours module which reached 97.9%. 12 modules fell below the 90% compliance threshold, with compliance vary significantly across modules. The lowest performance was recorded in resuscitation paediatric immediate life support Level 3, which reached only 54.9% compliance.

The trust took part in the Patient Led Assessment of the Care Environment (PLACE). These assessments aimed to ensure that patients received care in a clean, safe environment that promoted dignity and compassion. They also gave patients a direct voice in identifying areas needing improvement. PAHT demonstrated improved performance across all domains compared with their 2024 results. This included improvements within cleanliness, food and hydration, privacy, dignity and wellbeing and condition appearance and maintenance. Cleanliness scores exceeded the national average while food and hydration scores improved following targeted actions. PLACE information was last reported to the Board in January 2026.

The pharmacy department made education and training a core part of it’s outreach. The pharmacy education team supported medical students from Chelmsford and pharmacy undergraduates from the University of Hertfordshire through structured teaching sessions. Internally, specialist pharmacist in areas such as anticoagulation, antibiotics and frailty delivered regular training. They focused on key safety topics including polypharmacy and deep de-prescribing.

The trust had processes in place to identify, report and investigate incidents. The patient safety and incident response policy was in date at the time of assessment. The Incident Management Group met weekly to review returning incidents, new incidents and rapid reviews. Minutes showed that actions, identified learning and Duty of Candour updates were recorded. We observed strong attendance and appropriate multidisciplinary membership, which supported oversight and learning.

The trust was well equipped to support the national Patient Safety Incident Response Framework (PSIRF). Leaders had invested in developing organisational capability to support PSIRF. Patient Panel members had taken on the role of Patient Safety Partners and contributed actively to the PSIRF implementation group. They had completed both national and local training in patient engagement. The patient safety and quality team had undertaken the full five‑day PSIRF training programme, including investigation training commissioned through the ICB and regional providers. This strengthened the trust’s internal expertise. 2 to 3 members of the team had completed master’s‑level study in patient safety, and several senior nursing and operational leaders had also undertaken PSIRF training. Staff had accessed additional Health Education England (HEE) learning resources and Health Services Safety Investigations Body (HSSBI) investigation training as part of a structured training needs analysis.

Leaders understood that the trust’s mortality indicators had risen and took appropriate action. At the board meeting on 11 December 2025, senior leaders reported the trust standardised Mortality Ratio (SMR) had risen above expected levels and that Hospitalised Standardised Mortality Ratio (HSMR) and Summary Hospital level Mortality Indicator (SHMI) was also increasing and forecast to exceed expected limits within 4 to 6 months. Leaders had identified that the increase was due to problems with the EPR and clinical documentation and not the quality of patient care. Leaders had plans in place to improve documentation and coding and they expected performance to stabilise withing 4-6 months. Documentation and coding accuracy would remain a key organisational priority over the coming year.

To improve patient flow and safety, the pharmacist department was trialling pharmacist-led To Take Away (TTA) prescribing and enhancing its education framework across the entire organisation. This included a new strategy for non-medical prescribers and a "high-reporting, low-harm" safety culture that used shared learning to keep incidents below the national average. By measuring tangible outcomes like de-prescribing rates and TTA efficiency, the strategy ensures that pharmacy services were proactive, clinically integrated, and ready for future healthcare demands.

The evidence showed a good standard. The trust understood any negative impact of their activities on the environment. They strived to make a positive contribution in reducing this and supported people to do the same.

The Chief Finance and Infrastructure Officer was the board-level sustainability champion and the overall executive responsibility for driving the group was the Chief Medical Officer.

In 2020, the NHS became the world’s first health system to commit to reaching net zero emissions. The Health and Care Act 2022 reinforced this commitment, placing new duties on Integrated Care Boards (ICBs), NHS trusts and foundation trusts to consider statutory emissions and environmental targets in their decisions.

Leaders were engaged with the board approved 3 year Green Plan (2022-2025). They had worked collaboratively with the Integrated Care Board (ICB) and regional Greener NHS teams to deliver the objectives and priorities in the plan. An additional duty was placed on trusts in 2025 to publish and share a refreshed Green Plan by 31 July 2025. The trusts Green Plan Update 2025-2028 was presented at board in November 2025. The plan set out how the trust word further embed sustainability, aiming for a 38% reduction in carbon emissions by 2032 and aligning with NHS net 0 targets. Key actions focused on workforce, chemical transformation, estates, travel, and supply chain. The plan highlighted the need to prepare the trust estate for climate risks and the need to form a sustainability steering group regardless of future developments.

The trust received National Energy Efficiency funding of £359,000 plus VAT to switch to LED at the main Harlow site, and to add controls to the cooling system to reduce energy consumption. Construction of the Community Diagnostic Centre had been designed to achieve a Building Research Establishment Environmental Assessment Method (BREEAM). One of the world’s leading sustainability assessment standards for buildings. 100% of electricity was from certified renewable sources from Renewable Energy Guarantees of Origin (REGO).

Single use plastic had been replaced with alternatives in the restaurant and furniture schemes were in place to reuse and upcycle items. Food waste was sent for anaerobic digestions rather than landfill.