Hampshire and Isle of Wight Healthcare NHS Foundation Trust

On this page

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

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.

In assessing this Quality Statement, we considered feedback from leaders, staff, people using the services and local system partners, as well as reviewing trust processes and survey results.

Leaders demonstrated a shared vision and strategy to drive cultural change. They recognised there had been a cultural journey during transformation, where services provided by multiple organisations came together to form one trust. They were positive about the application of the trust strategy and vision across the organisation. Work was underway to improve and embed equality and diversity strategies within the trust.

Following the merger the embedding of the strategy was still in its infancy. Staff at various levels, including executives and frontline staff felt there was still a divide between clinical and operations impacting clinical decision making at times. This was improving as the new organisational structure embedded.

In October 2024 Hampshire and Isle of Wight Healthcare NHS Foundation trust was officially launched following the joining of two large NHS trusts and services from a further two trusts with the ambition of collectively overseeing the delivery of all community and mental health services across Hampshire and Isle of Wight. The formation of the new trust involved reorganisation of leadership into 7 divisional structures. These were four geographical areas (Mid and North Hampshire; Portsmouth and South East; Southampton and South West; Isle of Wight) and 3 specialist divisions (Secure, Acute and Crisis; Children and Families; Community specialist services).

The trust’s strategy 2025-2030 was launched in 2025 and consisted of 4 strategic aims and 12 strategic goals. The strategic aims were improving population health outcomes; delivering outstanding care; improving staff experience and delivering value for money. The trust’s strategy was supported by several sub-strategies including a green plan, digital and people strategy.

The strategy had been co-produced with people who used services, staff and stakeholders to understand what mattered most and drive improvements. This co-production had taken place through several placed-based events, staff events and surveys. There were 4415 survey responses, 160 attendees at co-design workshops, over 4500 community conversations, over 3080 staff attending virtual events, 2090 people reached through the Integrated Care Board citizen panel and over 200 conversations with staff and patients in inpatient settings.

The strategy aligned with the Integrated Care System and NHS plan for community-based, preventative and technology-driven care.

The trust provided examples demonstrating how partners had been engaged in the development of the trust’s strategy. Stakeholder feedback was positive; partners were satisfied that the trust’s strategic objectives were aligned to the objectives and priorities within the local system and felt the trust would be able to deliver against the strategic objectives. Some stakeholders felt that the strategic ambition was clear. One stakeholder felt that the strategic ambition was clear but there not always a consistent sense of urgency to drive transformation and achieve the trust strategy.

There was a consistent approach to reporting progress against strategic aims. All papers presented to committee meetings and board had an executive summary front sheet which clearly identified which of the 4 aims each paper referred to. The four identified aims included a set of priorities. For example, for population health outcomes there was a priority around how the trust ramped up the neighbourhood teams offer and to look at whether they were getting it right.

The trust had identified significant local variation across the Hampshire and Isle of Wight system, highlighting the need for major pathway redesign. Workforce succession and staff retention were also prioritised, with the Chief People Officer leading this work. Safety was flagged as another key area, focusing on strengthening the learning culture and expanding development opportunities for nurses, all within existing financial constraints.

The trust had launched a refreshed set of values which were Compassion, Accountability, Respect, Excellence (CARE). The trust had updated their meeting agendas to include a reflection by a staff member around CARE values at every meeting. For example, in the finance and performance committee meeting the chief of strategy and transformation shared the example of excellence and how the trust had learned from leaders in other trusts to understand their experiences of transformation and applied this within the trust’s strategy.

There was mixed feedback from staff about how the transformation program had been actioned following the coming together of legacy organisations. A CQC initiated staff survey showed that 47.5% of respondents agreed that they understood the trust's vision and strategy of where the organisation wants to be in the future. This included both clinical and non-clinical staff. Staff sentiment from the legacy organisations was that not a lot had changed and some staff feeling worse following the formation of the trust or concerned that the trust was too big. Staff felt that the leaders and managers usually represented the trust’s vision and values. However, comments also reflected that staff did not feel supported by leaders or that they lacked understanding. This included both middle and senior leadership levels. Executive leaders felt that all board members demonstrated and role modelled the values and behaviours.

At the time of the inspection the pharmacy strategy was in development to align with the organisational strategy with the aim focused on harmonisation and operational focus. Pharmacy senior leaders had engaged staff through away days, consulting on views to feed into this strategy. Following a restructure the operational balance had improved. Staff engagement included
one-to-one discussions and other forums. Patient feedback was included via the use of QR codes.

Executive leaders referenced the Patient and Carer Race Equality Framework (PCREF) and the trusts anti racist organisation plan throughout the well led assessment. The PCREF data report for 2025/2026 - quarter 2 detailed key findings for the quarter across a range of metrics. Headlines included that there had been a slight increase in females exposed to restraint and black patients showing the highest intervention rate and a learning point to strengthen ethnicity data capture as 12% of patients were recorded ethnicity of “not known” in response to incidents.

The Chief People Officer was new in post and had PCREF oversight within their portfolio. However, examples given during the assessment lacked clarity in how these met the parameters for PCREF. Staff understanding of the PCREF principles appeared confused and there was no evidence on how staff were being trained and supported to embed PCREF. There was a heavy focus on internal organisational change towards reducing racism. The trusts PCREF plan was launched on 1st September.

However, there was plans to develop health inequalities as part of future ways of working but these were in their infancy as a new organisation. The trust had published their working with people and communities plan in September 2025 which aimed to understand peoples experiences in using services and reduce health inequalities. This plan had been co-produced with people using services, families and carers. There was a drive for lived experienced to be at the centre of leadership roles and the organisation and was one of the strategic aims. Work was underway to improve feedback from hard-to-reach communities about the trust and to drive improvements. Due to the early stages of this outcome data was limited.

We saw evidence of efforts underway to create a positive safety culture and work was underway to continue to embed this as the trust moved from transitional state to business as usual.

The board was aware that further work was required to develop the culture of the organisation. The board told us that during planning they had underestimated the impact of the cultural piece of work with the coming together of two legacy trusts due to different ways of working and strength of feeling between legacy organisations and as such had not fully put measures in place to support staff to navigate implementation timelines and set expectations.

At the time of the well-led inspection there were still 21 teams going through consultation processes 12 months post initiation of the new trust. The priority was to now encourage staff to imagine the possibilities as the ethos developed and be involved in shaping organisational structures to achieve positive outcomes. The chief operating officer gave an example of how staff were involved in determining service line provision structures for specialist commissioned services.

Feedback from our ASG inspections indicated that there was strong team working identified at local service level but that there was a feeling of lack of support or understanding amongst more senior leaders. Staff reported low morale and workforce challenges. During the 6 assessment service group inspections we identified a consistent theme about inconsistencies in application of working tools and digital platforms which was impacting patient safety and service delivery. Inconsistencies were reported in job role titles and expectations, and staff spoke about the challenges with the transformation and consultation processes.

This feedback was reflected throughout the well led assessment in staff interviews and focus groups. For example, Staff did not always feel able to raise safety concerns and challenge unsafe practice. This was in part attributed to the changes in staffing structures during consultation or a feeling that their concerns would not be listened to or escalated appropriately.

The trust promoted learning and being open and transparent when things went wrong in relation to patient safety incidents. However, we saw limited evidence of how learning was disseminated across the organisation and leaders acknowledged this was an area of further development to build confidence in this. For example, staff reported feeling that if they raised safety concerns these were overlooked or ignored by the leadership team in favour of financial savings or reducing wait times, this was particularly noted in our assessment of mental health acute services. Staff felt that there were unsafe admissions to the ward and impact on staff and patient wellbeing as a result.

The Freedom to Speak up Guardians felt able to have the appropriate discussions with the board but that they had to be boundaried at times with some of the requests from board. Staff who acted as trade union representatives and staff who acted as chairs of staff equality networks we spoke to gave mixed feedback about the attitudes of senior leaders, some were positive but others felt that there was little involvement to ensure their voice was heard.

The trust had processes to identify and address behaviours that were inconsistent with the values of the NHS. The trust’s grievance and disciplinary policies were within their review dates at the time of our assessment. We heard examples of the grievance process and that work was underway to review this further in line with the trust's updated strategic vision.

We observed the trust board meeting, attended several governance meetings and reviewed minutes from board committee meetings. In all the meetings we saw leaders acting with integrity, effectiveness, credibility and kindness. The non-executive directors provided appropriate challenge to discussions to promote improvement and review. Meeting packs with agenda and papers were circulated ahead of each meeting to promote accessibility of information and review to maximise efficiency in discussions.

The trust’s board comprised of 8 executive directors including the chief executive and 10 non-executive directors including the Chair of the trust. The formation of the new trust in October 2024 resulted in a new trust board. The majority of leaders recruited to the board were made up of executive and non-executive directors who had been in roles at the former organisations which had merged, however some were externally recruited for their specialist skill. In the past 12 months membership of the board had fluctuated with staff departures and subsequent recruitment. In July 2025 the chief nurse and chief people officer were holding these roles in an interim capacity following the departure of previous executives. They were acting up in these roles from within the organisation to provide stability whilst recruitment occurred. As of October 2025 all executive leadership roles had been filled and there were no longer any interim executives.

There had been recent changes to the non-executive directors (NEDs) with some coming to the end of their tenures and new NEDs recruited. All NEDs recruited into the organisation received an induction. The trust had made progress in developing the organisational structure and processes, and now that board leadership had stabilised there had been a focus on embedding board workshops and development days.

The new chair of the board joined in April 2025. The chair worked closely with the chief executive to bring together and build the relationship of the board to drive the strategic vision and values.

The board had ambitions to deliver the strategy and a focus on communities. The chair of the board was aware of the challenges faced from bringing together legacy organisations with distinct entities into the formation of a new NHS Trust. The trust chair had a background in people management and used this to work closely and collaboratively with the board to identify areas for development and strengths within executive and non-executive leaders including recruiting staff who would bring a strength to partnerships and communities. Work was underway to additionally recruit a NED with a finance background and someone with partnerships and communities backgrounds to add to the skillset of the board and close a significant gap. Governors supported the induction program.

Leaders told us that succession planning needed further development as there was currently no one on a succession pathway ready to step into board and executive roles. There was not an embedded process in place to support development of staff of the global majority into these roles.

We heard from leaders and from staff that in the past few months there had been a shift with enhanced team working at board level with a commitment from leaders to represent trust values. NEDs described workshops to develop working relationships and more about structure and processes. We heard from some executive and non-executive directors that the current leadership structure felt refreshing and different to the dynamics observed under the previous structure. However, at the time of the inspection this had not filtered down to frontline staff who felt that local leaders were not always demonstrating the values.

Fit and proper persons checks were in place for all directors in line with the requirements of the regulation. All files we reviewed showed the trust had completed appropriate checks of directors’ suitability for their roles.

The trust was organised into 7 directorates. These included four geographical divisions and three specialist divisions. The specialist divisions spanned the whole system footprint. Each division had triumvirate leadership made up of directors and service level leads with a reporting structure up to board. Each division was at a different stage of the transformation program with some areas still undergoing consultation processes.

Staff attending focus groups told us that there were varying levels of support received from leaders. Overall, the consensus was that leaders more senior than their immediate line manager were not visible. As the strategy and divisional structure was still being embedded, we identified that key portfolios were split across multiple leaders making reporting structure, oversight and accountabilities challenging. This was fed back to us via staff in focus groups. We were told that as the leadership structure stabilised this was being streamlined and an improving picture. Staff reported that they were not always clear who to report concerns to due to multiple managers holding similar roles and responsibilities.

Under the divisional structure Allied Health Professionals (AHP) sat within each of the divisions. AHPs felt that there was a lack of representation of their role within the leadership structure and this was impacting on clinical decision making. We heard about plans to embed AHP leadership within the divisional structure and at director level to report upwards. However, these plans were still under development with some divisional structures having more AHP representation than others.

Leaders told us they undertook regular visits to frontline services. These visits improved leadership visibility and ensured leaders were able to triangulate the information received through the trusts governance system particularly in relation to staff experience. During the digital transformation in October 2025, leaders were “floor walkers” at key locations throughout the trust to increase visibility and assist with problem-solving. Feedback from staff via focus groups and staff survey results told us that staff felt leaders were not visible both at board level and beyond to divisional leadership. Staff felt that this impacted their ability to easily escalate risks identified at ward level and patient safety concerns.

The chair’s report presented at each board meeting clearly identified what visits the chair had undertaken to services. We did not identify that other board member visits had taken place although were told by executives that these had occurred. Evidence was subsequently submitted post inspection to demonstrate that from September 2025 to November 2025 executive leaders and triumvirate leadership undertook visits to services.

Findings from our assessment service group inspections consistently indicated that staff felt positive about their immediate line management structure but felt less positive about senior leaders. Staff reported feeling their concerns were not actioned or listened to by leaders. We received several pieces of feedback submitted to CQC anonymously about the leadership of the trust and attitudes displayed not being in line with the trust values.

Individual senior leaders were effective in bring about improvements in outcomes for people using services. The Chief Medical Officer had been pivotal in the quality and governance work around neighbourhood health work within the local health system. The medical director reflected on the learning from coroners inquest findings and recommendations and was looking to apply learning. This included driving enhanced communication with families and community mental health teams particularly around use of care planning and digital platforms and there was support for teams with enhanced training to ensure meaningful interventions.

The chief operating officer described a ‘left shift’ in working and a priority to support population health outcomes ramping up the work on neighbourhoods and getting it right in the community around accessing services.

Leaders were knowledgeable about the risks impacting service delivery. These were reported on through the Board Assurance Framework and risk record which sat under the BAF. We observed the appropriate challenge from NEDs around the BAF content and risks presented.

The Chief Pharmacist was accountable to the Chief Medical Officer and held responsibility for the governance of non-medical prescribers. Additionally, the Chief Pharmacist was the Controlled Drugs Accountable Officer (CDAO), ensuring compliance with statutory requirements.

Regular engagement occurred through monthly one-to-one meetings with the Chief Medical Officer and meetings involving divisional directors. These structures enabled effective communication and ensured that the voice of pharmacy was represented across multiple forums.

Partners told us they felt that the trust board had the experience, capability and personal values to lead the trust. Most partners were positive about individual leaders and shared examples of positive partnership working. Examples shared included joining local system calls to discuss pressures and opportunities to solve these. Partners also described that the trust leaders were leading the development of the virtual ward program across the system.

Feedback from system partners was that quality and safety issues were appropriately shared. System partners felt leaders had the appropriate skills and were visible and engaging in key system partner meetings both at board level and local triumvirate leadership.

In assessing this Quality Statement, we considered feedback from leaders, staff, people using the services and local system partners, as well as reviewing trust processes and survey results.

Staff knew how to raise concerns, report incidents and suggest improvements. Staff did not always feel confident to raise concerns openly and directly with leaders but were happy to have Freedom to speak up (FTSU) raise anonymously on their behalf.

Leaders told us they role-modelled good speaking up behaviours and listened to feedback and concerns. However, staff felt that this was not always demonstrated by leaders. There was a strong speak up program within the trust, they demonstrated candour and empathy when things went wrong, and they celebrated speaking up.

Data presented to the board in the FTSU report highlighted that whilst not directly comparable to national averages, internal data and surveys indicated that staff felt confident to raise concerns and were largely satisfied with the service received. Data indicated that the trust was generally better performing than the national average in these areas. The trust people pulse survey from July 2025 was presented at audit committee meeting and evidenced from the total of respondents 25.6% of staff said they wanted to speak up about an issue in the past 12 months and that 71% of those went on to raise their concerns. For those that did not, results showed that the highest reason for not doing so (27%) was feeling that nothing would change as a result. This is lower than annual survey and national survey data at 38%.

Results from a CQC initiated survey of staff at the trust indicated that nearly 95% of staff knew how to raise a concern. However, 18% stated they would not feel confident in doing so. Feedback included that they were afraid to speak out or not confident in that action would be taken or that retaliatory action would be taken against staff. This feedback was echoed by staff we spoke to throughout the well-led inspection.

Staff in some areas felt leaders would act to address concerns, however, others felt that there was a blame culture which was pushed back onto staff.

Leaders told us they encouraged staff to speak up and raise concerns. The board undertook service visits to support frontline staff to share their experience.

Within the pharmacy team, an open-door policy was maintained, even virtually, allowing staff to raise any issues with the senior leadership team. Monthly meetings provided an additional forum for staff to raise concerns openly with active conversations around speaking up encouraged. The pharmacy team had Freedom to Speak Up guardians within the team, and staff could also access guardians elsewhere in the trust.

The Freedom to Speak Up Guardians (FTSUG) told us that the most frequent themes at 76% related to attitudes, behaviours, harassment, bullying and worker wellbeing. 42 consultations, across 21 teams were ongoing so there was lots of contact with the FTSUG about anxieties about the change process. There was a perception that reporting concerns may influence their job retention. There had been a change in themes reported with an increase in acuity within the mental health units influencing reporting and temporary staffing increases around worker wellbeing. The FTSU team measured protected characteristics and demographic data in the surveys with 71% of reports raised by white British staff. This was proportionate to the staffing population demographic.

Staff were made aware of the FTSUG through workplace champions. There was 1.6 Guardians at the trust. There was between 40-50 champions within the trust and further recruitment underway. The champion role was promoted by the FTSUGs and champions spending 50% of their time being out with the teams speaking to people. 200 site events and visits had been completed in the previous 12 months. They attended wellbeing team events and through media forums including internal webpages and other social media channels including a staff social media page. The FTSU guardian felt able to confidently raise concerns to the board and to challenge appropriately whist maintaining boundaries. Staff received training in FTSU.

Partners felt the trust had a culture where staff could feel free to raise concerns. They said they knew this because if a FTSU escalation was provided to partners the provider gave effective responses into information requests. Partners felt there appeared a good connection between FTSU and safety embedded into quality reports which were visible to leaders around themes and trends.

The trust had a Freedom to Speak Up policy in place. The policy had been updated to reflect changes in guidance from the National Guardian’s Office.

The Chief People Officer was the executive lead responsible for Freedom to Speak Up. There was also a non-executive Freedom to Speak Up lead.

The trust board received a bi-annual (six-monthly) report into Freedom to Speak Up. The latest report presented to board in June 2025 showed the numbers of staff raising concerns via the trust’s Freedom to Speak Up process had increased since the previous year. The data available prior to the well-led review showed 322 concerns had been raised by staff in 2023/2024 (time period ending March 2024, and date combined from all legacy trusts). This had increased to 407 by time period ending March 2025.

The majority of staff told us that leaders aimed to continually review and improve the culture of the organisation in the context of equality, diversity and inclusion. A CQC initiated staff survey indicated that 70% of responses were positive to ‘agree’ or ‘strongly agree’ that the organisation acts fairly towards staff regardless of ethnic background, gender, religion, sexual orientation, disability or age.

Leaders discussed how they worked to achieve a more inclusive workplace supporting staff to work flexibly, a team culture of respect, kindness and understanding. For example, the introduction of remote doctors and psychologists and the introduction of the trust values and behaviours. Discriminatory behaviour and unfair treatment were not tolerated.

However, comments received by staff at focus groups and from free text responses to the survey raised concerns. Staff with protected characteristics including race and disability shared negative experiences of applying for promotion, opportunities to act-up and/or development opportunities. These included examples about racism, ageism and professional development particularly as the trust went through transformation and identifying new roles or job consultations. We received feedback about staff perception that people with caring responsibilities were not being catered for and that staff were having to take redundancy as there was a lack of flexibility.

The NHS Workforce Race Equality Standard (WRES) is a tool to support the NHS to be an inclusive and fair workplace and is designed to support organisations to identify improvements to manage and monitor inequalities through 9 workforce indicators. The trust scored slightly worse than the national average for the indicators identified in the 2025 NHS staff survey indicating slightly worse experiences for these staff members when compared nationally. Headline data included:

In 2025 there were 13,521 staff in substantive roles of which 16% were from Black, Asian and Minority Ethnic (BME) background. Government Census data from 2021 for Hampshire and Isle of Wight indicated that approximately 13% of the local population was from the same demographic meaning a representative workforce.

BME staff were 2.74 times more likely to enter formal disciplinary processes than white staff. This is broadly in line with benchmark data and national trends and an improvement upon the legacy trust scores. However, the trust have recognised this as an area to continue to focus on.

Staff identifying with an ethnicity from the global majority were twice as likely to have experienced bullying harassment or abuse from patients relatives or the public in the past 12 months compared to white colleagues (43.4% comparable to 21.3%).

Leaders were aware of the data and had action points in place for areas where they were below expected averages. For example, ensuring adverts were disseminated within global majority communities to encourage their application and to promote recruiting and developing into bands that are underrepresented. However, it was unclear when action would be taken and who would maintain oversight of progress against these.

There was not an embedded process in place to support development of staff of the global majority into these leadership roles although the Patient and Carer Race Equality Framework (PCREF) plan and anti-racist organisation drive were beginning to address this. The quarterly PCREF data report for November 2025 evidenced that the trust workforce was more ethnically diverse than the local working age population. However, BME colleagues representation dropped sharply from NHS payscale band 7 upwards and white colleagues were over-represented in bands 7-9 (traditionally leadership roles). Future reports were highlighted to include further equality outcome measures (staff access to study leave, further training, promotion and disciplinary measures) as these were missing from previous and current reports.

The trust board was not representative of the diverse population of Hampshire and Isle of Wight. There was no representation from the global majority for people in executive leadership roles. The trust recognised this was an area needing improvement.

Staff described seeing more diversity in terms of LGBT and gender representation into leadership roles but not for ethnicity and that there were no concrete plans in place to address this by the board. The demographic of the NEDs was more representative of local community.

NHS Workforce Race Equality Survey data indicated that the trust still required further work to improve promotion and career prospects for those from the global majority. However, since the formation of the new trust data was better than predecessor organisations. Leaders felt there had been a big step towards driving improvements in this field with the use of AI to remove bias language from recruitment adverts.

The trust performed equal to the national average for the 7 Workforce Disability Equality Standards (WDES) from the 2025 NHS Staff Survey, which illustrated the experience of staff with long term conditions or illnesses at the trust. The trust had identified that there had been an increase of 0.8% in the disability declaration rate to 5.7% of the total workforce which is above the national benchmark. The trust identified further work around staff declaring disability through the trust HR systems and a plan to work with staff networks to improve psychological safety and communication to increase reporting. Although priorities had been identified action had not yet been taken to address this

The relative likelihood of non-disabled staff compared to disabled staff being appointed from shortlisting across all posts was better than comparable benchmarking data. The trust had achieved disability confident employer status.

Leaders were committed to making the trust an anti-racist organisation. Leaders were aware that further work was required to develop equity and diversity within the organisation. The trust had identified this aspiration to form the next stage of the implementation of the people plan which had been on pause awaiting the new Chief People Officer who at the time of the well led inspection was 6 weeks into post. During the well led inspection we found it challenging to identify who took ownership of equality and diversity principles to drive this forward. When discussing equality and diversity the WRES and WDES data was discussed. However, there was no discussion from leadership or data presented about gender equality and pay or other protected characteristics. There was a lack of understanding of PCREF and how to apply this.

The trust had processes to monitor fairness in recruitment and career progression to ensure equally good outcomes for staff in equality groups. The trust had an action plan to address the indicators with improvement identified in the WRES and WDES reports.

The chair of the people committee recognised the trust’s need to further develop their succession planning for people from the global majority. This was echoed during other senior leadership conversations. Leaders recognised that the senior leadership team was not representative of the wider workforce but explained that work was under way to review the barriers for staff from the global majority applying for more senior leadership roles. Leaders explained that there had not previously been the pathway to support staff development into these roles and that further work was required to ensure there was a pathway plan in place. Executive leaders had met with governors to explore this further and ensure oversight. The people plan highlighted the work with local universities, communities and rural areas to support equality and diversity principles.

Workforce planning included regular gap analysis to identify resource needs, supported by business cases and benchmarking against NHS data. A pharmacy board reviewed workforce priorities and agreed actions collectively. However, workforce gaps persisted, particularly in community mental health teams, where pharmacy input was limited. Harmonisation of roles and banding had also been difficult, requiring engagement with staff. Morale had been low due to restructuring and workload pressures.

The trust works closely with universities to develop placements for their own pharmacists, “grow their own” workforce where they can. Medicines Administration Technicians (MATs) are highlighted as a valuable asset to medicines safety, demonstrating the trust’s recognition of diverse roles within the workforce. Flexible working was supported, and wellbeing resources were available.

We heard from the staff networks that some positive work had been in place to support colleagues with protected characteristics including providing extra support to staff during the anti-immigration riots that took place across Southampton and other Hampshire towns and cities in 2025.

Staff forum and staff side reps indicated that staff from the global majority were 2.7 times more likely to be involved in disciplinary processes than their colleagues. The leadership team planned to undertake a deep dive into why this may be but had not yet started this piece of work. There was a drive through the trust anti racism PCREF plan to reduce inequalities and provide supervision sessions for staff to challenge bias.

Staff networks included womens race equality, staff carers, neurodiversity, LGBT armed forces families and disability networks amongst others. Staff felt it was harder to action changes compared to previously and that recruitment delays were impactful. Staff cited the sickness absence policy as an example of delayed policy migration and that it was not as detailed or effective as previous.

The womens network was highlighted by staff forum representatives as at risk of failing due to limited support from executives. The armed forces network had received low representation in the months running up the inspection due to the administrative burden to run events and meetings alongside workforce demands and challenges and there lacked clear structures for lines of accountabilities. Some network chairs felt they need to step down in their roles within the networks as they were frustrated and felt opportunities had been missed to develop key processes. However, other network leads felt supported by executives.

Partners felt the trust actively promoted equality, diversity and inclusion both internally and within the local system. Partners were aware of the trust’s staff equality, diversity and inclusion networks. Partners were positive about the commitment demonstrated by leaders to supporting equality, diversity and inclusion particularly around lived experience work.

Governance systems were in place and constantly under review. Many governance processes were new and not fully embedded. This followed a harmonisation process to review policies from predecessor organisations to develop a single set of policies reflective of the new organisation. At the time of the inspection this program of work was underway but incomplete. This was to support the wider cultural piece of work. Staff reported that they felt governance processes were not currently robust but recognised the development. Risk management processes were in place to align with the new board assurance and risk frameworks. Work was underway to continue to improve these as the trust embedded new tools.

The trusts board assurance framework (BAF) was reviewed in 2025 at the same time that the trust strategy was introduced. This ensured strategic risk to the strategy aims were aligned. This included the streamlining of three predecessor risk documents into one overarching strategic risk document. The refreshed BAF had developed to become a dynamic living document showing how the trust faced risk and board members felt that the operational process was more robust than previous versions. The BAF was reviewed at every committee meeting for areas of risk relevant to that committee.

The BAF summary dashboard was presented at the October 2025 board meeting. The dashboard was organised by each of the four strategic aims. This showed the trust remained at ‘red’ or ‘amber’ for every risk indicator identified. Underneath the dashboard sat detailed risk plans and actions to achieve projected targets for lowering the risk score. The BAF dashboard reflected that many risk scores had reduced with time and the detailed document demonstrated progress against these.

The top identified risks included people (retention and recruitment), digital (cyber and integration) and finances (doing well and cost savings fast forwarded). There were action plans in place to address each of these areas. A data security protection toolkit was added to cyber security oversight teams to ensure it was embedded in governance structures. For cyber security there was an action plan in place to drill down into what the risks were including around harmonisation of policies.

The risk management group maintained oversight of risk and had created a new tool for oversight. The risk pyramid clearly identified the relationship between top three risks within each of the 7 divisions top 5 organisational wide risk domains, top 5 organisational wide risk groups and the board assurance framework risks.

A review completed by external stakeholders in 2025 as part of a transactional agreement in bringing together legacy organisations identified that the way divisional leaders oversaw incidents in line with the Patient Safety Incident Reporting Framework (PSIRF) needed to be strengthened. The trust was in the process of embedding a learning and governance oversight process group to address this.

Following the formation of the new trust from two large predecessor organisations the trust had embarked on a 12 month harmonisation project to create new trust policies. Leaders told us that this process had taken a long time but had been done diligently, taking the best elements of policies from the previous organisations into new policies. This harmonised approach was praised at the public board meeting in October 2025.

At the time of the well led inspection not all policies had yet been revised. Staff spoken to during the inspection told us that policies they were working to were confusing due to the harmonisation being incomplete and did not always know where to find the policy they required. The Pharmaceutical team told us that harmonisation of policies had been a challenge. The BAF included strengthening governance systems as a key risk for consideration currently scored as “amber” and further work was required to achieve their target on this.

Future planning was in place to streamline digital platforms to a single system following the transformation. This was recognised as a large piece of work to complete and was on the trusts priority list to action. As a large mental health and community trust, the trust was currently operating from multiple enterprise resource planning (ERP) systems which were not always compatible with each other. An ERP system is an electronic platform to oversee processes such as finance, business and HR tools. ERPs are also used for electronic patient records storage. This meant that when patients transferred between healthcare teams their clinical notes were recorded on different systems, posing a risk that important clinical information may be lost during transfer between teams. This had been highlighted as part of the wider digital risk under the BAF.

Consultation processes were ongoing to identify managerial structures within the trust’s directorates. Frontline staff reported feeling confused about who to report information to as some directors and executive leaders had multiple or shared portfolios of work. The trust had been part of a governance review and had engaged well with system partners. There had been some recommendations and learning taken from this.

The trust had been established under a dual structure system (geographical and divisional). Leaders told us that the effectiveness of this structure would continue to be reviewed. Feedback from staff during the inspection was mixed about the effectiveness of having a mixed structure in terms of information sharing and learning.

There was mixed feedback provided by partners in terms of governance although this was mostly attributable to the time needed to embed processes following the formation of the trust.

Partners told us that they were aware of the trusts governance systems and processes. The trust met with partners quarterly to review framework standards and was in routine surveillance for quality and safety in line with national quality board and the NHS ICB post transitional merger process. The trust implemented feedback from partners in response to governance structures.

In September 2025 the trust embarked on a major harmonisation program migrating legacy organisations onto one single training platform. Following roll out further developments were needed for system effectiveness. As such a trust wide agreement was made to pause individual staff training platform updates for 3 months. A mandatory training oversight group had been established with their first meeting taking place on 12 November. Staff reported difficulties in completing mandatory training due to multiple training platforms and some challenges with IT literacy which was being addressed through support packages. Mental Health Act training was at 75% which was discussed as an area of concern during the board meeting. The board were aware of the issue and plans were in place to address this. There were also challenges in booking face to face training due to issues booking trainers.

The trust had a process for gathering, analysing and escalating performance data in an accessible format to the board consistently and regularly. The data presented to the board was in the Integrated Performance Report (IPR). This had been refreshed to create a new integrated dashboard for reporting.

There was lots of agenda items for the quality and oversight committee. The chair told us that this made it challenging to ensure appropriate scrutiny of data. There were plans to further develop and strengthen oversight of quality and performance in line with the embedding of the newly completed executive board.

The medical revalidation process was working well with HR oversight in place for any consultant cases requiring General Medical Council (GMC) oversight. There was appropriate support in place for the development of consultants and newly qualified consultants as well as GPs and continued professional development opportunities. Medical staff felt the clinical governance processes were becoming more linked with the corporate governance level and helping response to risk.

The trust had effective governance and oversight of the staff use of the Mental Capacity Act (2005) Code of Practice to inform patient’s decision making and the use of the Deprivation of Liberty Safeguards. The most recent audit was completed in the 2024/25 audit cycle, where concerns were identified these were acted upon.

The trust had effective governance and oversight of the staff use of the Mental Health Act. The trust was registered with the Care Quality Commission for assessment or medical treatment for persons detained under the Mental Health Act 1983. There were appropriate measures to ensure that peoples’ rights were respected and that the powers were used correctly to keep people safe. CQC MHA monitoring visit reports were sent to the relevant clinical leads who formulated responses. The visit reports and responses were discussed at the mental health law oversight committee meeting as a standard agenda item. MHA policies were up to date and leaders prioritised policies according to review dates and national guidelines.

The Medicines Management Group (MMG) reported into the Trust Quality Group. Medicines Safety Officers actively participated in governance activities and external forums, including ICB sub-groups. Despite these structures, significant challenges remained with financial constraints and workforce shortages. The transition to a fully digital prescribing system was ongoing, with inpatient wards largely on electronic prescribing medicines administration (EPMA) but outpatient systems facing delays. Some areas still relied on paper, and technical issues with discharge summaries had led to difficulties in transferring accurate medicines information to GPs in a timely manner.

The trust had processes to prevent and control infections. The trust’s board received an annual and mid-year infection prevention and control report. The trust had effective governance of Infection prevention and control measures that meant the trust complied with the requirements of the National Infection Prevention and Control Manual (NIPCM) for England. The trust’s board received an annual and mid-year infection prevention and control report.

There were processes to manage the financial resources and sustainability of the trust. The trust had an experienced chief financial officer in post. They were confident the trust would achieve the financial plan for the year breaking even although recognised the integrated care system as a whole was unlikely to achieve plan due to the need to provide financial support to stabilise the wider system which was in the NHS England recovery support program due to financial challenges with one of the acute hospitals. The underlying financial position was a deficit but this was improving and the trust was trying to maximise the savings from the merger of legacy organisations into the new trust. Any financial or strategic decisions were subject to a quality impact assessment, with clinical input and to an equality impact assessment.

The trust had oversight of third party contracts and service level agreements. There were processes to ensure the integrity and confidentiality of data, records and data management systems. The trust was one of the few trusts nationally to achieve the standard ‘met’ in the last Data Security and Protection Toolkit (DSPT) which was mapped against the Cyber Assurance Framework (CAF) this was a direct result of the trust having a dedicated Cyber Security Assurance Team which covered cyber security across the whole organisation. The trust’s MDE exposure score measuring vulnerability to cybersecurity threats and prioritise improvements was better than the national average meaning they were less likely than the average trust to be vulnerable to threats. Antivirus and patching compliance for the trust was at 95%. The trust scored better than average for all of the cyber security and information governance metrics. This was achieved through robust processes and cyber security risk registers.

The trust had good oversight of their estates and equipment. Risks relating to the fabric of the buildings and environment were mitigated. The trust had identified through their ligature audit work that further work was required to bring estates into risk oversight and clinical/operational discussions. We saw examples from the newly formed patient safety committee (mental health focus) how estates were involved in these key discussions. There was also a paper going to board about developing the relationship between estates and clinical work. This was particularly important when discussing the male medium secure unit and to expose ligature issues across the organisation.

The trust understood the communities they served and was working to ensure that all people using their services were treated fairly. There were processes in place for the trust to review health inequalities data. This work was being developed by the engagement team to survey hard to reach communities and expand neighbourhood working. There was a direct reporting structure up to board to share information and improve patient outcomes.

There were known business continuity plans for use when unexpected events occurred and created a risk to the delivery of the service.

Leaders at the trust invested time in building relationships, understanding perspectives and constructively engaging with partners within integrated care boards, place-based partnerships, provider collaboratives and other relevant forums, including primary and social care partners.

There was effective oversight and governance of partnership arrangements which ensured information was shared in line with the relevant legislation and best practice guidance.

The trust’s governors told us they felt supported to undertake their roles and represent local communities. Governors received an induction and training for their roles. Governors could access specific workshops and were supported to undertake visits to services. There were areas of geography where there was an underrepresentation of governors, however, a recruitment process was underway.

Leaders gave examples of how the trust worked in partnership with other organisations both within the local system, the south east region and nationally. The trust collaborated with system partners on the health and wellbeing board place based better care fund and was noted to have a clear leadership presence in these meetings. The trust had supported the ICB with its digital priorities and working closely to agree priority cohorts for the roll out of digital innovations. For example, the trust have been looking at a digital program of shared care record video consultations and document sharing with primary care.

The trust Chief Medical Officer co-chaired the system Neighbourhood transformation board and the Chief Nursing Officer chaired the system sharing record steering group.

There was external collaboration by the pharmacy leadership team with the Integrated Care System (ICS) prescribing committee, Integrated Care Board (ICB) medicines management group and various regional pharmacy networks. Internally, the pharmacy team had a dedicated training lead who attended NHSE training and supported meetings for the region, and Medicines Safety Officers (MSOs) that actively contributed to national MSO forums. The Chief Pharmacist attended the South of England Chief Pharmacy group who met every quarter to share learning specific to mental health across the geographical area.

The trust was involved as a partner in the Hampshire and Isle of Wight, Sussex, Kent and Medway (HSK) provider collaborative for Children and Young People Mental Health (CAMHS). They were also part of the South East perinatal provider collaborative (SEPCC). The SEPCC reported looking forward to building relationships with more visible leadership from the trust as governance structures embedded and although not a lead provider they were hoping that the trust will take on the transformation agenda.

The Mental Health Act Law oversight committee had good representation from system partners including the local authority, IMHA, police and secure transport ambulance services. There were daily bed management calls to prioritise MHA assessments and transfer of people to Health Based Places of Safety. Multi agency policies and protocols were in place and reviewed in partnership to ensure collaboration. The trust attended PAN Hampshire meetings for 136 suites.

The trust’s strategy was co-produced with people in the community. The trust had a focus on delivering neighbourhood care and working in partnerships with the community including the prioritisation of lived experience. The trust had employed a director to oversee the experience of care and strengthen involvement with communities and to improve how feedback was gathered from seldom heard patient groups. There was a targeted focus to hear these peoples experiences. The care in the community group was formed by the trust and held over 1600 conversations both within and external to the organisation across every protected characteristic to understand barriers to accessing care. The team had engaged with over 300 community groups registered with the trust including those in hard to reach areas and used over 5000 pieces of feedback to shape health promotion and address inequalities in the community. For example, the team met with a community group in Portsmouth for Bangladeshi Women to discuss diabetes care. A chef was brought in to support nutritional understanding and the facilitation of single sex exercise groups such as Badminton. Another group of individuals living with mental health conditions had been utilised to share their stories in the community and within the trust to promote quality improvement.

The trust had developed a five year plan titled working with people and communities and had been drafted by the engagement and experience team in September 2025. The focus of the plan was to strengthen partnership working in the communities and to address health inequalities by identifying barriers and amplifying solutions to access care provision. For example, they had introduced a carers information plan and booklet making it easier for carers with loved ones using services, creation of women’s health events, empowering uptake of breast and cervical cancer screening offers and use of creative methods such as slam poetry to engage veterans, contributing to the trust being accredited as being veteran aware.

The trust was actively trying to encourage people to use the complaints process. The trust had begun identifying and building relationships with groups identified as less likely to complain through their community and partnership working with local charities and organisations to ensure feedback was collected. This was in the early days of implementation, and the trust wanted to expand this.

The trust had revised their process for collecting feedback through the engagement team and had collated over 18,000 pieces of feedback from various digital sources including the friends and family test, compliments, carer and patient support hub and others. During quarter 2 (July – September 2025), the trust had received 49 complaints which was 1 more than in the previous quarter. The trust was currently meeting the NHS criteria for a response time within 3 working days. There was a focus to continue to aim for early resolution but also recognition that there where there was significant patient safety issues these may take longer. Five complaints in quarter 2 were resolved later than the 30 day target.

The trust worked in partnership to safeguard people. We received positive feedback from system partners about their participation in safeguarding adult boards.

People using services were involved in improvement and innovation. For example, there was co-production of the trust strategy which involved the views and opinions of those using services to develop it. The work with partnerships and communities had led to increased feedback from community organisations to shape these services. However, this was being embedded. Service user representation at board and committee meetings was improving. For example, at the October board meeting there was an agenda item which included a patient story presented by named staff member.

The trust described itself as becoming a learning organisation and acknowledging that this culture was still developing. Board members reported an improved culture of supportive challenge of each other to drive improvements and that had improved over the past 12 months.

The trust had an annual audit plan. This internal audit progress report informed the audit committee about progress against plans and delivery. The internal audit plan for 2025/6 included scoping work for the following audits, IT operating model (EPR strategic review), staff wellbeing, Fit and proper person test, data quality, outpatient clinic management and recruitment and retention. Under the previous 2024/25 plan audits included waiting list management, quality accounts, Mental Capacity Act and Deprivation of Liberty Safeguards and data security protection toolkit. There were additional audits identified with timeline dates. Each audit had an executive lead to maintain oversight. The review of completed audits presented included areas of strength and areas of concern and ways to address these.

The trust was part of several accreditation programmes including Veteran Aware accreditation, Quality Network for Forensic Mental Health Services, Perinatal Quality Network accreditation, Electroconvulsive Therapy accreditations service, Quality Network for Psychiatric Intensive Care Units, Quality Network for Community CAMHS accreditation provided by the Royal College of Psychiatrists amongst others.

The trust engaged in many research projects. Minutes from the trusts research, continuous improvement and transformation group meeting in September 2025 demonstrated that between April to September 2025 824 participants had been recruited into 31 research studies. The trust was ranked 4th out of 43 mental health trusts in the national institute for health care and research league tables.

Leaders described innovation to improve safety including the use of virtual psychologists and consultants in a drive to improve challenges with accessing care and treatment.

In our survey of partners, we received mostly positive feedback in relation to this quality statement. The trust were joint improvement leads to support system wide learning and innovation and were noted to play a key part in delivering a modern GP model across all practices the trust ran. The trust had been leading with the Neighbourhood development program across some localities and attendance at system wide QI conference with the trust taking the lead on organising some of the QI week.

The trust was described by partners as the systems “anchor network” due to the size of the organisation and influence in system based discussions to improve outcomes for people.

The trust had processes to ensure staff accessed professional development and support to provide care. During our assessment service group inspections, we saw evidence from staff of a culture of promoting staff internally into leadership roles. Staff told us they had taken on positions in senior leadership and felt supported to do so. Staff were also moved to roles in different teams to promote their learning and good practice to drive improvement.

The trust had systems to learn from deaths, inquests, patient safety incidents and alerts from national bodies. The systems were effective and highlighted learning. However, there was a delay to processing and investigating some patient safety reports which meant that lessons were not always learned quickly to help avoid similar incidents reoccurring.

The trust’s processes for learning from deaths focused on a holistic review of patients who died whilst in the care of the trust. Reports from death reviews showed that learning was identified and used to bring about improvements for other patients.

The trust reviewed mortality process prior to the merger and had identified large differences between the two trusts. As such the trust developed clear reporting criteria to bridge the differences this included developing a single dashboard for data analysis. The aim was to embed within the electronic reporting system and to upskill individuals in accurate reporting and learning from incidents through this.

The mortality review group and sub division groups had been created as part of the formation of the new leadership structure within the trust to ensure better oversight of data.

Divisional leaders were responsible for implementing the lessons learned from deaths. As part of the harmonisation process the trust was reviewing the policy and what was required under PSIRF and what was to be recorded under learning from deaths. This was still being developed and needed further work to be embedded.

Twenty-six deaths that occurred between April and June 2025 were referred to patient safety for learning. The Learning from lives and deaths – people with a learning disability and autistic people (LeDeR) was being reviewed by the trust but had identified it was challenging to get data on currently. 10 were reported to LeDeR. The trust was in the process of attempting to get data and cross reference against protected characteristics.

The trust engaged in various community groups around suicide prevention which had been highlighted as higher than average in Hampshire. The trust was in the process of improving the quality committee to make it more effective and ensure the appropriate information was presented to embed a learning culture. Leaders acknowledged this was an area to continue to develop to ensure the learning culture was embedded.

Leaders expressed confidence in the trust’s initial incident review processes which ensured that immediate learning from incidents was identified and shared.

The trust Patient Safety Incident Response Framework (PSIRF) priorities had been agreed. The PSIRF plan had been agreed for November 2025. The response framework highlighted the expectations for reporting structure and the action groups depending upon the level of criteria for learnings. This was to remove the subjective nature of decision-making. The paper presented to the quality oversight committee on 3 November 2025 identified for the most recent reporting period six patient safety incident investigations had been closed and six reported for Quarter 2.

Delays to divisional governance structures had impacted timeliness of report sign off at the PSIRF meetings but that timeliness of reporting and sign off had been improving recently. However, further work was required to embed governance structures. There was evidence from the reporting that incidents were reviewed with initial learnings and investigation updates, and timelines for any that were still under review.

The trust showed strong commitment to continuous learning and innovation in medicines optimisation. A dedicated training team of pharmacists, technicians, and medicines administration technicians deliver structured programmes and ad hoc sessions, including support for acute services. Staff were encouraged to complete independent prescribing courses and clinical diplomas.

The trust was an early adopter of two electronic prescribing systems, improving prescribing safety and addressing interface challenges between primary and secondary care. Other innovations include a psychopharmacology training programme to close mental health knowledge gaps amongst staff. Continuous improvement was supported by Quality Improvement facilitators, medicines safety officers, and a research and innovation pharmacist working on clinical trials.

There was a systematic approach to improvement which meant that improvement was embedded across the trust. There was evidence of investment in improvement in terms of time being made available, money and upskilling people where there was a skills or competence deficit. Human factors were considered and addressed.

Leaders understood their responsibilities relating to environmental sustainability. They were able to provide examples of where the trust had made changes to reduce the trust’s carbon footprint.

The trust’s chief of digital and strategy was the board lead for the trust’s green plan. Areas of focus included the digital transformation, estates and medicines.

The trust demonstrated a commitment to reducing the environmental impact of its pharmacy services. One priority was the reduction of carbon emissions from inhalers. The trust was working to transition from metered-dose inhalers (MDIs) to dry powder inhalers, which have a lower carbon footprint. This change aligned with the local Integrated Care System’s prescribing guidance that prioritised the lowest carbon emission inhalers. Efforts to minimise medicines waste were ongoing. The pharmacy operated an electric van for medicines distribution instead of petrol vehicles and encouraged virtual meetings to reduce travel-related emissions. Additionally, the Chief Pharmacist participated in the Medical Gas Committee, working closely with estates to monitor and mitigate gas leaks.

The trust had a continued focus on achieving their strategic vision including assessing its environmental impact and delivery. Estates oversight was part of the board assurance framework and had a risk score of 16. The trust had set a target risk score of 12 by December 2027 and had a set of actions identified to achieve this. These included developing a single estates strategy developed from the trust clinical strategy and reflective of 10 year plan, designing a new estates team and way of working, design a new case for the medium secure unit replacement including funding routes, continue engagement with ICB on estates, ongoing monitoring of impact. Current issues affecting the risk score included gaps in funding for the male medium secure unit & also around Child and adolescent mental health services and legacy settings on the Isle of Wight.

There was a carbon emission plan in place to monitor and drive greener service provision. There was evidence on the BAF that the score around carbon emissions had reduced from 20 to 12 in the previous 12 months. The trust had set a target risk score of 9 by 2030. There were actions in place to achieve this.

Partners were aware that the trust had a green plan. The trust plans were aligned with wider system plans, particularly the local integrated care board Green Plan.

The trust had a green plan for that reflected NHSE guidance and with the national Greener NHS Guidance. The green plan identified how the trust would manage the environmental impact of implementing the strategic objectives set by the trust board.