Humber Teaching NHS Foundation Trust

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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has remained good.

Good: This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

Leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued. Governance processes operated effectively. Performance and risk were managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected and analysed data about outcomes and performance. They used this to identify improvements.

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

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The service had a relatively new leadership team, and positions such as the ward manager, clinical lead, clinical psychologist and occupational therapist had been in post between 3 and 7 months at the time of our inspection. The leadership team were working with frontline staff to ensure there was a positive culture, with clear vision and values and that this was applied in the work of their team. Leaders and managers were engaging with staff, people who use services, relatives and other stakeholders.

Leaders and managers told us staff were being given the opportunity to contribute to discussions about the strategy and improvements for their service, especially as the service was changing. The team at Townend Court had completed some ‘Being Humber’ Workshops which included reviewing the quality plan, discussing culture of care and new objectives. We spoke with 8 members of the staff team, the divisional lead, ward manager and clinical lead who were honest about the current challenges and ways in which the service could improve. Most staff felt able to raise any concerns and highlight areas for improvement and this was acknowledged and supported. External partners and relatives that we spoke with were also able to raise any challenges they encountered or concerns they had, and this was met with understanding.

Leaders and managers could explain how they were working to deliver high quality care within the budgets available and the trust shared with us their project plans regarding timescales, finances and estates for the service redesign.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had the skills, knowledge and experience to perform their roles. Leaders had a good understanding of the wards they managed. They could explain clearly how the teams were working to ensure good care and discussed improvements being made to improve outcomes for people who use the service.

Leaders were visible in the service and approachable for people and staff. Staff spoke about positive and effective handovers, regular and effective supervision sessions and access to training and development opportunities within the trust and staff were positive about recent changes regarding this.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff we spoke with knew how to raise concerns and were able to raise concerns through a variety of feedback methods. They felt leaders were supportive and approachable, and dealt with issues appropriately and efficiently. Staff were aware of the whistleblowing policy and procedure in place. Staff had access to a freedom to speak up guardian and staff we spoke with knew how to contact them and who they were.

However, the last staff survey was carried out in 2024 and learning disability services scored lower in 9 out of 10 People Promise themes when compared to the trust results. This included the theme regarding ‘we each have a voice that counts’ which scored 0.16 below the trust target. Managers had access to the feedback from staff and used it to make improvements. Following the staff survey, learning disability services had created an action plan which was due to be completed by December 2025. These actions included recognition and reward, working flexibly, compassionately and inclusively as a team, improving morale and impact on service users.

People and relatives told us they had opportunities to give feedback on the service they received in a manner that reflected their individual needs.

People, staff and relatives could meet with members of the provider’s senior leadership team and governors to give feedback.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Equality and diversity were actively promoted and staff told us felt they were treated equitably. The staff team included wellbeing champions to support the team through raising awareness of wellbeing activities and initiatives, promoting healthy lifestyles and positive mental health.

Staff were supported with reasonable adjustments or flexible working arrangements to support them to carry out their role and to account for personal circumstances, where relevant. The provider undertook equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the patient group. The last staff survey was carried out in 2024 this included a subtheme regarding ‘Diversity and Equality’ which scored 0.46 below the trust target. The learning disability services action plan included an action focused on diversity and inclusion and support for protective characteristics to create a more positive experience for underrepresented groups.

Staff had the appropriate training in equality and diversity and at the time of inspection, staff training compliance was at 96%.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There was a clear framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed.

Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed.

Staff understood the arrangements for working with other teams, both within the provider and externally, to meet the needs of people using the service.

Staff maintained and had access to the risk register at ward or directorate level. Staff at ward level could escalate concerns when required.

The service had business continuity plans in place for emergencies.

The service used systems to collect data from wards and directorates that were not over-burdensome for frontline staff.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, worked well and helped to improve the quality of care. Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care.

Information governance systems included confidentiality of patient records. Information was in an accessible format, and was timely, accurate and identified areas for improvement.

However, maintenance of the environment was poor, and it did not meet the needs of all people using the service. The service had clear redesign and development plan in place to address the current challenges to enable the environment to offer shared and lone spaces, segregation, and engagement opportunities, provide a sensory environment and enable staff to manage risk and support and allow for person centred care.

The service did not ensure people’s care plans were consistently followed and where they worked in partnership with people and external agencies to agree strategies to deliver person centred care, this was not always achieved successfully.

Quality Statement Score: 3

We scored the service as 3. 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.

The hospital had good working relationships with external providers such as adult social care, safeguarding, independent health advocate and future care providers. We received feedback from 5 external partners, who provided us with some positive feedback such as, “Staff have always supported advocacy support for my advocacy partners and facilitated this very well.” They also told us about collaborative working to support people who use the service, “I have experienced collaboration with Townend Court during a recent Care (Education) and Treatment Review. All relevant staff from Townend Court were in attendance alongside social care, placement providers and other specialities with the purpose of the review to promote equality and remove barriers to discharge for the person.”

Directorate leaders engaged with external stakeholders such as the Care Quality Commission, commissioners and Healthwatch.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Staff had opportunities to participate in learning and development and make suggestions for quality improvement initiatives taking place in the service. This included a recognition from the trust and senior leadership team that the current environment was not suitable for the current patient group, and plans were in place to make improvements to the physical environment to meet people's sensory and physical needs. Staff used quality improvement methods and knew how to apply them through regular audits by both staff and leaders and by creating action plans to address issues identified.

The hospital was working towards meeting the core commitments of the Culture of Care Standards which as an initiative embeds a culture of collaborative and person-centred decision making and practices to improve experiences and outcomes for people. The service was also introducing a peer support role to devise and carry out a sensory audit, which would use thefivesensestoevaluateandreviewthe ward environment andsurroundings.

Staff participated in national audits relevant to the service and learned from them. For example, the service had recently had a Patient-Led Assessments of the Care Environment (PLACE). Ward managers informed us this had been a positive experience, and they had received some feedback regarding the damage to the environment and fixtures and fittings.We did not see a copy of this assessment, as it was due to be published in February 2026. The actions from the assessment are monitored through the trust’s health and safety group and the quality standards group for full oversight.

The trust recently launched the Connect website and the team won the highly commended award in the category of ‘Learning Disability Initiative of the Year’ at the Health Service Journal (HSJ) Patient Safety Awards for the project.

The service was focusing on improvements and training for the multi-disciplinary team in mentalisation based therapies (designed to enhance an individual’s ability to understand their own and others mental states to improve emotional regulation).