East London 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.

The trust had a refreshed strategy with a delivery framework so it could be translated into action. The trust worked strategically to meet the needs of its populations addressing health inequality. 

The trust had some poor estates which impacted on the ability to deliver therapeutic care. There was an estates strategy, which was 

considering options for refurbishment and potential reprovision of current mental health inpatient services but this had not concluded.

The approach of the leadership team created a positive culture for the organisation. However, the staff survey indicated that groups of staff were having a difficult experience at work. The trust was sighted on this, and had a workstream to make improvements, but further work was needed.

Trust leaders had ensured there was a clear mission, with values and a strategy in place for the organisation. The trusts mission was to improve the quality of life for everyone they served. The values had not changed since our last 2 inspections. These were – we care; we respect; and we are inclusive. The values were well known and understood across the trust. 

At the time of this well led inspection, the trust strategy had just been refreshed and launched. The strategy for 2026-31 was developed through an extensive programme of engagement involving staff, service users, carers, governors, communities and system partners across all the trust geographies. The strategy was being launched through a programme of place-based roadshows, led by members of the executive team. The strategy was presented on 2 pages and was clear and accessible. 

The refreshed strategy articulated the reasons for change and was aligned to the NHS 10-year plan. It recognised demographic changes in the population, the need to focus on prevention and the growing use of digital technology. 

The 4 strategic priorities remained unchanged. These were to improve people’s experience of care; staff experience; population health and value. We could see that the work of the trust was framed around these priorities. For example, each paper which went to the board stated which of the strategic priorities the work aligned with and the implications of the work being undertaken. 

All the governance processes showed clear alignment to the 4 strategic priorities. For example, all papers for the board and other governance committees identified which strategic priority they aligned with. 

At the May 2026 board there was a presentation of the strategy delivery framework. This described how the trust intended to translate the strategy into practical action. The trust had deliberately not developed a detailed implementation plan. Instead, they had a structured approach to support prioritisation, coordination, learning and organisational mobilisation over time. There were plans for further engagement so that local leadership teams could be supported to develop and embed their plans. These measures would be supported by data which would enable progress to be monitored so there was accountability. 

The trust, as part of its strategy, had a strong focus on improving population health. The trust was the first NHS ‘Marmot Trust’ which meant they were testing the boundaries of what an NHS trust can do, as an ‘anchor organisation’ in their local area to tackle some of the drivers of poor health such as poverty and unemployment. It had produced an annual population health report to share the work they had undertaken. The third annual population health report was published in January 2026. It described some of the work being done to support young people and families; promote employment; prevent homelessness and promote the physical health of people with long term mental health conditions and a learning disability. For example, the healthier, wealthier families initiative in Newham and Luton had helped homeless people open bank accounts, supported people to receive specialist immigration advice and provided learning for young people to improve their financial awareness. This was done in partnership with local councils, Citizens Advice and banks. The trust had also worked in partnership with employment support services and other charities to help people into employment. 

The trust continued to work strategically to meet the needs of the populations it served. Since the last well led review, the trust had cemented its collaborative work with its neighbouring trust, North East London NHS Foundation Trust. There was now a joint chair and collaborative working of the boards and executive leaders alongside other operational staff. This joint working had resulted in many positive developments, particularly in relation to access to mental health services for people with mental health needs in North East London. 

The trust had several enabling strategies. Throughout the inspection we observed or heard from staff concerns relating to the environments impacting on the quality of care for people using services and well-being of staff. There had been some discrepancy between the patient led assessment of the care environment (PLACE) and what inspectors saw. The trust had an estates strategy. This focused on improving the management of immediate environmental risks, whilst delivering a long-term plan to provide modern, flexible environments that enabled the implementation of new models of care. This prioritised investment in aging infrastructure using a risk based approach. The trust was considering options for refurbishment and potential reprovision of current mental health inpatient services (particularly in Tower Hamlets and Hackney), but this had not concluded. In Bedfordshire there were plans to replace the inpatient facilities, but funding shortfalls needed to be overcome. A programme of refurbishment of the forensic inpatient facilities was commencing shortly after our assessment. 

The trust had developed a medicines optimisation strategy.  At the time of the assessment work was underway to ensure that medicines optimisation priorities were fully aligned with the new trust's organisational strategy. There was a strong emphasis on medicines optimisation being viewed as everyone's responsibility rather than solely the responsibility of pharmacy services. The chief pharmacist described efforts to embed pharmacy and medicines optimisation within wider organisational priorities and governance structures. The chief pharmacist was a member of several leadership forums, providing opportunities to influence strategic discussions and ensure medicines optimisation was considered within wider organisational decision-making groups. 

Throughout the inspection, staff said the trust board were visible and accessible. The board meetings took place in London, Luton and Bedfordshire. There was an active programme of executive and non-executive director visits to services. Non-executive directors gave feedback to the board following their visits and there were processes in place to escalate any urgent concerns so they could be addressed. There was a monthly chief executive breakfast with staff across the trust geography. There was a monthly chief executive discussion group with members of the senior leadership team. All staff webinars took place hosted by members of the executive team. Staff commented on the approachability of senior leaders in the trust. They told us they had good access to leaders and felt they had a good understanding of the challenges in their service. 

We heard from people about the culture of the trust, where the first thought was always for the patients. We observed staff across a range of services being kind and caring to people who were using services. The work being done to improve therapeutic engagement on inpatient wards meant that staff demonstrated a good understanding of the importance of getting to know the people they supported and understanding what was important to them. 

Staff repeatedly told us that the most significant change since the last well led inspection had been the need to closely manage trust finances. This had resulted in a number of measures, including service reconfigurations and other cost saving measures, impacting every member of staff, such as managing the amount of leave which could be carried over into the next year. This had widely impacted staff morale and senior leaders reflected that they had learnt from this process that there was a need to improve the communication and how the changes were made. 

The 2025 NHS staff survey had a response rate of 51%, an increase of 18% from the previous year, and above the average response rate of 49%. Many staff told us they enjoyed working for the trust. However, they also described the pressures they were experiencing and the impact of this on their ability to deliver high quality care. 

This was reflected in the results of the staff survey 2025 which had lower results across the majority of people promise themes. The trust scored lower than the national average in 7 of the 9 key areas. Three priority themes required focused improvement; flexible working and retention; learning and development (including appraisals and development opportunities); safety and wellbeing, particularly burnout, negative experiences, and health safety climate. The trust scored above average in 2 key areas of the 2025 NHS staff survey: ‘We each have a voice that counts’ and overall staff engagement.

The trust had made improving workplace culture a strategic workstream of their staff experience programme. They had identified 6 habits for teams to action to create healthy and happy teams. These were regular supervision; team away days; huddles; use of data; people participation and use of quality improvement. The inspection found that in very stretched front-line services staff were struggling to implement these actions. 

Feedback from system partners recognised that the trust had strong leadership that was engaged with system work and working in partnership to deliver some services, for example, community health services in East London. There was good collaboration to ensure information was shared with services both internal and external. Leaders maintained strong external relationships through participation in a range of regional networks and leadership groups. The chief pharmacist chaired an integrated care board (ICB) medicines value group. 

The trust had arrangements to work with trade unions. Trade union representatives commented that trust staff had not previously experienced the current level of financial challenge. There was awareness of the ‘going further going together’ programme to address this. Some representatives also expressed the view that the trust could feel London focused. This had been raised and an increasing number of meetings were being convened in Luton and Bedfordshire. There was also some discussion in relation to the length of time some grievances could take to be resolved. Trust data showed an over representation of global majority staff in disciplinary cases and over representation of some staff groups. This was an area the trust were exploring to understand more fully the drivers behind this. The trust was also doing quality improvement work in relation to disciplinaries focusing on three areas – timeliness, compassion and early resolution and equity. Staff side raised concern at what they perceived as an increase in the number of cases relating to dignity at work – grievances that could take some time to be addressed.

The trust had an experienced, committed, dynamic board which was ably led by the chair and chief executive. Clinical leadership worked well throughout the trust at a board and directorate level. Clinical leaders understood their roles and accountability. The organisation of the leadership team supported good connectivity within the organisation and with external systems and stakeholders.

There had been significant changes in the executive leadership team and non-executive directors since the last well led inspection. These changes had gone well and provided an opportunity to introduce people with the breadth of experience needed to support the strategic direction of the trust. For example, non-executive directors had been appointed with experience of organisational development; digital and artificial intelligence (AI).

The board was diverse and reflected the communities it served. The trust continued to show a strong commitment to clinical leadership, with most executive directors and directorate level leaders having clinical backgrounds.

Board members, spoke knowledgably about the strategic direction of the trust. They were passionate about the work of the trust and how they could contribute. Non-executive directors were very aware of the need to continue with the concerted efforts to achieve an open culture and reported that the behaviours of the executive and board as a whole were open, supportive but challenging when required, truly working as a unitary board. We observed insightful questions and thoughtful challenge at the board meeting.

Since the last inspection a joint chair had been introduced working across the neighbouring mental health and community health trusts in North East London. The 2 boards met together regularly and had joint development sessions to enable them to develop how they utilised the benefits of their combined strategic work. 

The more recently recruited non-executive directors (NEDs) confirmed that they had received a good induction to familiarise them with the trust including site visits and meeting all the executives and other NEDs as part of the planned induction. One NED referred to a webinar they were invited to prior to applying for the NED role. The webinar was attended by approximately 100 people and gave the executive and others the opportunity to explain the values and vision of the trust to ensure those that applied understood the culture and ethos of the trust to ensure a good 'fit'. Each NED had direct access to the chair as required and made use of this when needed as well as gaining support from the 2 deputy chairs.

The trust had a fit and proper person policy. Board members had completed checks in line with the requirements. This included a thorough search of their social media. The trust had strengthened the fit and proper person policy and procedures since the last inspection. We looked at the fit and proper persons checks for 8 board members, including everyone who had joined the board since the last inspection. Appropriate checks were completed looking at original documents where needed. The annual reviews did not just rely on board members completing a self-declaration, there was now a formal 1:1 review.

An annual appraisal was undertaken, and each NED had a development plan which was supported and facilitated by the chair. One NED confirmed that the NEDs were very self-motivated and driven to develop.

There were regular board development days using external facilitators where appropriate. This covered a range of topics. A session was planned to review the board assurance framework and risk appetite. 

The portfolios of the executive board members were kept under review. At the time of the inspection the chief quality officer post was vacant and after recruitment processes no appointment had been made. In the interim the portfolio had been shared across the executive team and executive directors said they were managing this additional responsibility. Following the inspection a director of quality role was created for a fixed period of 12 months. This ensured dedicated leadership for key elements of the portfolio while learning from the previous recruitment processes and considering the longer-term structure and requirements of the role. Executive directors continued to be buddied with NEDs. Executive directors also had lead and champion roles. This included leading on priority areas of work, linking with a geography in the trust and championing a staff network. For example, the chief digital officer led on cyber security, linked with the director of Health and Care Space Newham, and was the lead executive for the women’s network. 

The trust continued to ensure that services in Luton and Bedfordshire and London received appropriate levels of executive oversight and support with the continued appointment of deputy chief executive roles covering each of these geographies. 

Allied health professionals, psychologists and social workers felt well led and that their views were represented in strategic discussions. The chief pharmacist reported directly to the chief medical officer and described positive working relationships with senior executive colleagues and feeling well supported. 

The trust was organised into 8 directorates, mostly geographical but also specialist services. The directorates had well developed leadership teams. These teams had extended from including a traditional manager, medic and nurse to include other professionals and people participation staff. Senior leaders from the directorates valued their autonomy within a framework and their ability to respond to the needs of the people who used their services. 

The trust reviewed leadership capability and capacity on an ongoing basis. A board succession plan was in place. Senior leaders in the trust had individual development plans linked to their career aspirations. This supported them to access a range of opportunities including mentoring, coaching, experience of work external to the trust, formal training and reflective practice. During the well led inspection the chief operating officer was appointed to a chief executive post in the neighbouring trust. Following the inspection a chief operating officer was appointed. We heard how senior staff from directorate leadership teams had undertaken personal development so they could apply for more senior roles should they wish to do so. 

Leadership development opportunities had been strengthened since the last inspection and were available for staff who were aspiring to be managers as well as existing managers. During the inspections, we heard many positive examples from staff who had accessed development opportunities. The trust recognised the importance of promoting the competence and confidence of line managers as a key part of improving staff experience of working in the organisation. The trusts ‘Lead programme’ was a leadership development course designed for staff typically in Band 5 to 7 roles. It focused on building core leadership skills, managing change, and understanding population health.

Arrangements to support staff to speak up were operating well within the trust. Themes were appropriately identified and fed into governance processes, so that leaders across the organisation could address these issues as appropriate. The staff survey 2025 identified that staff felt able to speak up but did not always feel confident that that these would be acted upon. The trust were sighted on this and were building this into their ongoing work to improve staff experience.

The trust had a freedom to speak up strategy and policy. A freedom to speak up guardian (FTSUG) had been appointed and incumbent in post since 2020. In addition to the full-time FTSUG, 14 freedom to speak up champions had been identified across the trust to promote awareness. The FTSU was line managed by an executive director and met bi-monthly with the trust chair and chief executive officer (CEO) to discuss themes and issues from FTSU contacts. 

All staff received information in relation to speaking up during induction. The FTSUG and champions also attended team meetings and team away days as well as producing a quarterly newsletter. In addition, the regular trust wide bulletin included a FTSU slot. During our inspection of community and inpatient services we found there was good awareness of the FTSUG and their role. 

The 2025 NHS Staff Survey showed that staff agreeing with the statement ‘I feel safe to speak up about anything that concerns me in this organisation’ had fallen slightly from 75% in 2024, to 74% in 2025. This was above the national average of 64%. The survey also showed that in 2025, 53% agreed with the statement ‘If I spoke up about something that concerned me, I am confident my organisation would address my concern’. This was a slight increase from 52% in 2024. The trust score was slightly above the national average in 2025 of 52%. 

The FTSUG reported to both the people culture and quality committees, submitting regular updates to them and the board. The trust had consulted on and refreshed its speaking up strategy in 2024. 

The November 2025 update report to the quality committee identified 80 contacts from 1st April 2024 to 30th September 2025. Twenty-one related to patient safety or quality issues, a 50% increase on the previous reporting period. Some of the increase in the numbers of reports was attributed to the launch of the speaking up strategy, increased promotion of speaking up and new systems which meant staff could report concerns anonymously. Immediate quality and safety concerns were escalated to the chief nurse. The update report broke FTSUG contacts into broad themes and also considered which staff groups were making contact. The November 2025 update report identified that processes and organisational structure, inappropriate attitudes or behaviours and worker wellbeing were the primary concerns raised, followed by bullying and harassment. Workstreams addressing these issues were in train. A new inphase system had been introduced to support the FTSUG in the management of cases. 

At the time of our review, the FTSUG advised that concerns were predominantly raised by staff working in child and adolescent mental health services and substance misuse services in Bedfordshire. The trust had taken some actions already to understand this and were continuing to monitor FTSUG referrals closely. 

The trust valued diversity in their workforce. They were working towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff networks were actively supported by the leadership of the trust. Where the trust was an outlier, for example in the numbers of global majority staff who were entering disciplinary processes, this was recognised by the trust with plans in place. 

The trusts equality, diversity and inclusion (EDI) strategy focused on eliminating health disparities, tackling structural inequality, and fostering fair practices regardless of race, age, disability, gender, or sexual orientation. A range of EDI data and action plans, with progress and updates, were regularly reported to the board and its sub committees.

Each directorate convened an equality forum and had identified a patient and carer race equality framework lead. The equality forum had oversight of directorate and individual team and ward EDI plans and their implementation. The directorate equality forums met each quarter, with an identified executive lead, to share updates and progress on their action plans. Trust wide, there was an EDI committee, which reported to the people sub-committee of the board. 

The trust had appointed an EDI lead to support the implementation of strategy trust wide, provide support and information to communities of practice and the staff networks. They also prepared reports and other documentation for the board and its sub committees. 

The trust aimed to put equity at the heart of its services, encouraging each individual team to think about how they delivered equity in access and to be accountable for this. Teams were expected to develop their own ambitious equity plans which were scrutinised through the directorate EDI forum. Our service inspections indicated that this work was in its early stages. 

At the time of our review, the trust had developed its anti-racist charter, which was being launched by the board in September 2026. The trust strategy was aligned to the North East London integrated care system strategy. As part of its development there had been consultation including co-production with people participation groups, board development days, the race staff network and local communities, including local Jewish communities and Jewish trust staff. Once signed off, the anti-racist charter would sit under the main trust strategy and had been identified as a year 2 priority. 

The trust chief people officer regularly reported to the board regarding equality, diversity and inclusion work. Data from the 2025 NHS staff survey showed that in relation to the work force race equality standard (WRES), global majority representation in the workforce and board was better at ELFT than at most NHS trusts, which reflected the diversity of the local population. The trust was well-placed to deliver care that was culturally competent and met the needs of all patients. A greater proportion of global majority staff undertook non-mandatory training and continuous professional development than white staff in 2024/25.

The staff survey found that the experience of global majority staff in most of the WRES metrics, whilst still needing improvement, was the same or better than staff at other similar trusts. This included the likelihood of being recruited from shortlisting; experiences of harassment, bullying, abuse and discrimination and career progression for bands 5 to 7. In response, the trust was considering how it was assured about the performance of recruitment panels, with training provided to managers. A review looking at how structured development programmes, sponsorship and reciprocal mentoring could be more effectively deployed was underway. 

The experience of global majority staff in relation to disciplinary processes was an outlier for the trust. Global majority staff were 5 times more likely to enter the formal disciplinary process than white staff, which was the second highest disparity level of all NHS trusts and a sharp increase from the previous year. In response, the trust had reviewed its formal process with the aim of making it more equitable and timely; provided resolution training to managers aiming to reduce the number of formal referrals and launched a resolution process supported by mediators, to provide alternatives to the formal process. The trust had also identified a particular incident involving a cluster of staff that had impacted upon the data set. 

The trust was performing comparably well when reviewing most recent workforce disability equality standard (WDES) metrics. The percentage representation of disabled people in the workforce and on the board was higher than average, and almost equal rates of disabled and non-disabled staff were appointed from shortlisting. The trusts performance in ensuring that disabled staff were no less likely to enter capability processes had improved significantly.

There were areas for improvement. Most of the indicators highlighted that staff with a long-term condition or illness had poorer experiences than those without. The level of disparity was broadly in-line with or better than the level of disparity in the wider sector. In addition, 70% of ELFT’s disabled staff said their employer had made reasonable adjustments to enable them to carry out their work, which was the third lowest of all trusts in the sector. The trust had decided to move to a centralised reasonable adjustment team to simplify and speed up the process for staff. The trust had developed a comprehensive action plan addressing how it aimed to improve staff experience in these areas. Staff we spoke with during our focus group programme generally spoke positively of their experience of obtaining reasonable adjustments to support them in their role. 

Staff networks were consulted in the development of action plans in relation to the workforce race equality standard (WRES) and workforce disability equality standard (WDES).

At the time of our inspection there were 5 networks operating within the trust. These were: the men’s network, race network; women’s network; LGBTQIA+ network and ELFT ability network. Staff gave strong positive feedback about the support senior leaders provided to the staff networks. From our observations and feedback, we saw that whilst the trusts men’s group was establishing itself following its recent introduction, the other networks were well established and well attended. Each network had joint chairs who received protected time to fulfil their duties. Each network had an executive sponsor and a small budget. Each network was convening regularly, most often through TEAMS to ensure people could join from the whole of the trust’s geography. The networks also regularly presented to various board sub committees, ensuring issues raised and discussed within each were on the radars of the wider board. The network chairs met regularly for support and to share information. 

Since the last inspection, staff networks were working together innovatively to address issues of intersectionality. An intersectional staff network conference had been held. Network meetings included educational sessions, opportunities for peer support, and raising issues with senior management. Staff were able to raise their concerns through the networks including acknowledgment of change fatigue in restructuring of services, concerns about variable implementation of reasonable adjustments, and administrative staff frustrations about limited career development pathways. The women’s network was considering the different lighting needs of men and women (patients and staff) and were proud that training on the menopause was now part of staff mandatory training. 

The trust was aiming for gender pay equity. Its most recent report to board on the gender pay gap broke staff groups into lower, lower middle, upper middle and upper quartiles. The majority of male employees were in the upper quartile, whilst women were under represented in this quartile and over represented in the lower quartile. The gender pay gap between men and women in the administrative and clerical staff group was 15%. The trust had recently started gathering data to enable it to report on disability and ethnicity pay gaps. Measures to address pay gaps were included in the trusts EDI action plan. 

The trust governance arrangements were largely robust but would benefit from some additional strengthening. The directorates had autonomy within a framework to support them to meet the needs of local populations. However, the inspections of services found some unwarranted variation both between and within directorates, where trust policies and procedures were not always applied and embedded to the same standard. We also found areas of good practice which would benefit from being shared across services and directorates to improve the care being delivered to patients. There were examples of innovative arrangements for gaining assurance including a service user and carer led accreditation scheme which had 131 wards and teams participating. Whilst the mortality review processes were thorough and learning was identified, there were some clearly identified areas to improve patient safety where small-scale quality improvement work was taking place, but the level of concern warranted a broader response at pace. 

The corporate governance arrangements had remained similar to the previous well led inspection; they aimed to deliver oversight of quality, safety and performance. The unitary trust board consisted of 8 executive directors including the chief executive and ten non-executive directors including the chair. Board meetings were well structured and took place 6 times a year. Development events were planned between the board meetings. Part 2 of the board meeting was used appropriately, mainly to discuss safety events where the individual would be identifiable and areas of finance which were commercially sensitive.

There were 8 sub committees of the unitary board. These were quality assurance, people and culture, finance business and investment, audit, partnership and integrated care, people participation, renumeration and charitable funds. Key risks and updates were shared in a report from each sub-committee to the board. The non-executive directors (NEDs) were aligned to the sub-committees and also attended meetings which they did not chair to get a broader understanding of the work of the trust. There was a clear understanding of the role and work of each sub-committee. Sitting beneath the sub-committees of the board were executive committees covering the business of the trust. 

The oversight of quality safety and performance happened through several governance meetings. Senior leaders from across the organisation came together each week for a director safety huddle. Directly after was the executive team meeting, where executive directors focused on key priorities in relation to quality and safety, people, finance, performance and strategy. 

A monthly service delivery board maintained oversight of the directorates and services. This escalated risk and delivery issues to the executive team and trust board. The 8 directorates were held to account through quarterly executive quality reviews. These provided a structured, in‑depth review of quality, safety and performance at service or directorate level, supporting triangulation, assurance and learning. Where there were concerns about services, deep dives took place. Directorates were asked to present to the quality assurance committee and were also represented at other committees and events to promote learning. 

The directorates operated with autonomy within a framework. Each directorate had regular directorate management team meetings. Governance arrangements varied between directorates to reflect local populations, services and commissioning arrangements. The use of safety huddles was found across the trust. The ability for directorates to operate with some autonomy enabled creativity and an ability to respond at speed when urgent action was needed. The inspection did however find some examples of unwarranted variation. The agenda for governance meetings varied in some services, meaning that teams might not have the opportunity to learn about safety issues. Also, teams doing the same work in different geographical areas might not learn from each other’s good practice. For example, some crisis services had good quality personal safety plans for patients and others were not undertaking this work so well. Following the inspection the trust was working to strengthen its community of practice for community mental health, crisis and health based places of safety to standardise leadership and quality reporting whilst collectively working on quality improvement areas. More broadly the trust was also reviewing governance arrangements as part of its standard practice. 

Robust arrangements were in place to provide oversight and governance to the trusts Mental Health Act (MHA) functions. A MHA law group (MHALG) received quarterly reports from each of the directorates and the associate hospital managers. The group also received information in relation to incidents, CQC visits, quality improvement (QI) and legal updates. People who use the service were represented in the group. The risk register was reviewed quarterly. Six risks had been identified including; consent to treatment documentation and S132 MHA compliance. QI projects were addressing these issues, with data indicating that improvements were being made in these areas. 

The trust were monitoring data in relation to second opinion appointed doctor (SOAD) requests. An attempt at arranging SOAD clinics with CQC in early 2026 was unsuccessful. The trust were tracking the backlog of SOAD referrals and were aware that no progress had been made. Work was ongoing to ensure responsible clinicians knew what information they needed to provide to the SOAD service and that consultees were available. Since the inspection SOAD clinics had been relaunched, were operating well and reducing the backlog of referrals. 

The executive MHA lead chaired the quarterly MHALG. Findings from this meeting were reported to the quality committee and the board. The associate director of MH Law prepared an annual report to the quality committee. The trust had arrangements in place to monitor its compliance with the Mental Health Units (Use of Force) Act which came into effect in 2022. Relevant data, trends and concerns were discussed locally at directorate level. The trust was making data more accessible by using data insight tools and their electronic record system. A standard operating procedure was in place for MHA monitoring visits. Feedback from visits was shared within the relevant directorate and reported in the MHLG. There were plans to move all CQC information onto the trust’s risk reporting systems to give all directorates full oversight of concerns raised.

Within the trust restrictive interventions; such as physical restraint, seclusion, and rapid tranquilisation, were used only as a last resort to prevent immediate, serious harm. Appropriate policies and procedures governing their use were available to staff. 

During our visits to wards, we saw there were some restrictions in place on the wards, which were proportionate to maintain a healthy and safe environment. For example, outdoor access and some areas with ligature anchor points were supervised. Where appropriate, individual risk formulations were used rather than imposing blanket restrictions. Staff maintained and reviewed blanket restriction registers. The restrictive practices group and use of force group reported to the patient safety forum, chaired by a director of nursing. 

Appropriate systems to govern the management and administration of medicines were in place. Medicines governance was supported through a range of groups including the medicines committee, medicines safety group and the patient safety forum, with good multidisciplinary representation reported at these meetings.

Whilst the pharmacy service reported a low vacancy rate, pharmacy staffing pressures were evident within community mental health teams and crisis services, where resource limitations continued to create challenges. Work was underway to address this and the associated risks were monitored. Medicines-related incidents were routinely reviewed through established governance structures. Leaders reported there were clear escalation routes to ensure significant medicines concerns were considered by senior management and the board where appropriate. The pharmacy team had developed live dashboards using electronic prescribing and medicines administration (EPMA) and data warehouse systems to support monitoring of medicines-related activity. The chief pharmacist acknowledged that further work was required to strengthen performance reporting and develop meaningful metrics. There were 2 medicines-related performance indicators routinely reported; medicines reconciliation and discharge notification to primary care within 24 hours. 

The trust had multiple arrangements to gain assurance about the quality of care delivered across the trust. There was a programme of peer visits to services. The trust a service user led accreditation programme where 131 teams across the trust had self-assessed across 27 standards which were co-produced with people who use services and carers. The trust took part in 4 national clinical audits. There was an internal clinical audit programme including pharmacy related audits, health and safety audits and directorate specific audits. Feedback from this assurance work was fed back to teams and directorates to support improvement work. Whilst regular medicines-related audits were completed, it was acknowledged that implementation and follow-through of audit actions remained an area for improvement as recurrent themes continued to be identified through audit findings. 

Each directorate put current risks on the corporate risk register. The risks were scored and the actions to address them were clearly recorded. Progress with addressing the risks were monitored through the governance processes. Risks which posed a significant risk to delivery of the trust’s strategic priorities, or risks that could not be mitigated at directorate level were escalated through senior leaders at the service delivery board. We could see that the corporate risk register informed the board assurance framework maintaining oversight of significant risks which, if they materialised, may affect the strategic direction of the trust. However, it was not always evident when a corporate risk met the threshold to be on the board assurance framework. For example, there was an operational risk of cyber-security, and this was recorded as being on the board assurance framework. There were also multiple estates issues on the corporate risk register, and whilst estates were on the board assurance framework, this was not acknowledged on the corporate risk register. 

At the time of the inspection the board assessment framework (BAF) was being refreshed to align with the strategy with the amended strategic risks going to the appropriate board committees. The BAF aligned to strategic priorities and recorded 10 principal risks. Each one had an executive lead, identified the committee with oversight and the linked primary strategic priority. The BAF also highlighted links with high risks on the corporate risk register and the refresh was intending to strengthen this connection further. All recorded risks included the drivers of the risk and potential consequences with a risk rating. For each risk there were mitigations, agreed actions with dates and a progress update. The BAF was thorough and provided a robust framework for the board. 

Trust data showed an upward trend in numbers of deaths from 2021 to 2026 due to the improved reporting of deaths for people receiving community health services. The trust had commissioned a range of thematic reviews with partners to more fully understand trends and themes. At the time of our inspection a thematic review into unexpected deaths over a 4-year period and a thematic review into homicide had concluded, a thematic review of suicide was underway. The reviews completed to date did not indicate that the trust was an outlier or evidence an increased occurrence of patient safety events. However, there was evidence of recurrent themes in unexpected deaths. 

The trust carried out its mortality review processes robustly and with appropriate clinical input. Clear criteria identified where investigations were needed and this work was carried out thoroughly. At the time of the inspection the trust was bringing together all the recommended actions from the separate investigations to make sure that these were implemented across all the relevant services and not just in the part of the trust where death occurred. The themes and trends from the mortality review processes were identified and reported through the quality assurance committee to the board. 

The trust had systems in place to learn from deaths of people with a learning disability or autistic people (LeDeR). Staff reviewed and discussed data and learning from LeDeR reviews to identify and help reduce health inequalities for people with a learning disability or autistic people. We saw that the group discussed how the trust could make amendments to their systems to ensure staff could easily see a flag that a patient was autistic and may have specific accessibility or communication needs. The learning disability lead was in the process of improving staff knowledge of the relationship between a diagnosis of autism and risk of suicide.

The trust had moved to the patient safety incident response framework (PSIRF) in 2023. This was in line with NHS England guidance on how to respond, learn and improve patient safety. The trust had identified PSIRF priorities and at the time of our inspection these were coming up for review. Considerable effort had been spent in the roll out of PSIRF, ensuring staff understood what was staying the same and what would be changing. People who use services had also been involved in this process, co-producing some elements. In response to incidents a range of responses could be utilised to learn from the incident. Robust guidance and governance systems supported staff to identify the most appropriate response and provided oversight and scrutiny on completion. Learning from incidents was shared at local team level and within directorates. A monthly trust wide seminar aimed to disseminate trust wide learning and was supported by safety briefings and patient safety incident investigation (PSII) on a page. Recent topics in trust wide seminars had included; homicide; ligature risk and dual diagnosis. Some trust wide work streams had also been identified and were underway. These included a trust wide quality improvement (QI) project addressing observations and therapeutic engagement and a resuscitation QI project. 

There were some significant ongoing themes from the mortality review and PSIRF learning from incidents work. These highlighted recurring factors which had contributed to unexpected deaths. This included family and carer involvement; risk formulation especially for patients leaving inpatient facilities; communication between teams when people were moving between services. Whilst there were some examples of smaller scale improvement work to address these themes, there were no large-scale interventions such as the work on therapeutic engagement. Following the inspection the trust concluded its work on both the strategy and the supporting delivery framework to ensure that quality and patient safety priorities were clearly reflected and explicit throughout the documentation. Key patient safety metrics had been incorporated into the scorecards used to monitor progress locally and trust wide.

The trust was placed in segment 2 (above average) of the latest NHS Oversight Framework (NOF) segments data from Q4 2025-26, published 11 June 2026. The trust ranked 18th out of 61 mental health and community trusts nationwide. The trust was ranked as high performing for finance and productivity and below average for patient safety. The below average score for patient safety related to performance

against the standard for urgent referrals to crisis teams being seen within 24 hours which had shown a gradual improvement over the past six months, increasing from 70% in February to 77.4% in July 2026. Alongside this the trust were embedding work linked to the staff survey to strengthen effective team working and support psychological safety and speaking up. 

The trust had robust financial plans and oversight to ensure its ongoing sustainability. For 2026-27 the trust had an agreed plan to spend £709 million on the provision of services; and to invest £31 million on its estates, equipment and digital assets. The trust had bettered its agreed financial plan for 2025-26 reporting a small surplus. Work was in progress to deliver recurrent savings of at least £20.2 million for 2026-27. 

The audit of accounts for 2025-26 had been completed prior to the inspection and we were advised that external auditor had given an unqualified opinion and made no recommendations in its value for money opinion. Internal auditors had given positive assurance about the operation of internal controls, with some recommendations in relation to sickness absence and risk management. The trust had a visible and effective in house counter fraud team. 

The chief financial officer had significant professional standing and was about to leave the trust. Their successor had been appointed and a transition process was underway at the time of our inspection. The trust’s financial governance was overseen by the audit committee and the finance, business and investment committee (FBIC).  Both committees were chaired by senior, experienced non-executive directors with an effective focus on assurance of operational risk management. Awareness of the importance of the effective stewardship of public money was embedded within the trust.

The trust had taken measures to embed financial sustainability within its culture and values. They had identified the need to take action to reduce reliance on one-off sources of funding and to give assurance they could operate within their means. The trust had developed its ‘going further, going together’ programme to engage and take all staff on the trusts journey to drive improvement whilst addressing economic and efficiency issues. In addition, assurances about the operation of financial controls had been strengthened by reducing the use of corporate credit cards and cash. As a result of the trust’s success in the ‘going further, going together’ programme, they had been able to implement one-off programmes to reduce waiting times for adults and children with learning difficulties and autism using a mix of online self-assessment tools and in-person assessments. 

The trust acknowledged estates as one of its most significant strategic risks. The trust operated services from a mix of owned and rented premises. Backlog maintenance was assessed at between £80-90 million. The trust had made progress in increasing premises asset management assurance, although it acknowledged there was more to do. The trust had commissioned an external provider to review its asset management systems. 

The trust had a performance report which was presented at each board meeting with a summary of the main changes and where needed, how these were being addressed. The report was informed by a range of indicators and used run charts to see the direction of travel. The report highlighted areas of concern which included lengthy waiting lists. It also highlighted areas to monitor, for example the most recent report identified fluctuating incidents of violence and aggression. 

During our service inspections, we saw that overall, staff did support people with existing physical health conditions and promoted healthy lifestyles. On some wards more work was needed to ensure all patients received required physical health checks after intramuscular rapid tranquilisation had been administered. Work was underway to strengthen these checks. The trust had targeted quality improvement initiatives aimed to address health inequalities for people diagnosed with a severe mental illness who face a shorter life expectancy. Local QI projects in this area included improving the completion of physical health checks, improving joined up care with other disciplines and improving links and communication with GP practices. In 2024, the trust inaugurated the first Bedfordshire wellbeing games. The event provided an opportunity to try a range of free taster sessions from golf, seated yoga, swimming and badminton to basketball. The aim of this annual event was to promote the benefits of sport and activity for everyone’s wellbeing and in helping people’s recovery from poor mental health. 

The trust had a dedicated centralised infection prevention control (IPC) team who were able to offer support to locality teams. The team produced trust wide IPC policy; provided training; carried out audits; supported clinical service development; monitored infections such as MRSA and clostridium difficile; supported inpatient staff when an outbreak of infectious disease occurred; educated visitors on their responsibilities during visits and collaborated with stakeholders and partners as part of system wide IPC measures. The chief nurse led infection prevention control across the trust. An infection prevention and control committee reported regularly to the quality assurance committee and quarterly to the trust board.

Across the trust, robust systems were in place to monitor and improve pressure care. Within community health services, pressure care oversight was overseen in team meetings; skin matters groups; red, amber, green risk meetings and through escalation to local directors of nursing. Pressure care data was collected weekly. Locality-level reports and learning summaries were disseminated to community teams. Where high incident numbers were identified, a deep dive review was undertaken and findings shared with clinical leads. Any grade 4 pressure areas were automatically reviewed using a patient safety incident investigation. To promote safe practice and reduce preventable harm, the trust had implemented monthly, trust wide learning sessions open to all staff and a reflective learning pressure care tool. 

The trust had identified a range of training courses as mandatory. Across the trust, for all courses, the compliance rate was above 90% in June 2026. However, some individual courses were below this level. They included; adult life support; breakaway training and safer prescribing of medicines. We were told there had been some issues in accurately reflecting when training courses were completed as the trust moved from a manual to computer system, with work underway to address this. There were also sometimes issues with staff not attending face to face training courses. A weekly huddle at director level had been implemented to monitor and drive increased compliance with mandatory training. Compliance with mandatory training was also monitored for bank staff. Paid, protected time to complete mandatory training was available to bank staff. As a result of these actions completion of mandatory training was improving. Regular, unannounced life support simulations were taking place on London inpatient wards. Breakaway training was restricted to staff assessed as unable to complete prevention and management of violence and aggression mandatory training. 

Trust wide data indicated that supervision in all but one directorate was below 80%. Across the trust, 4 of 13 directorates were below 80% in complying with appraisal targets. The trust advised that they had not been confident with their data as this had been manually gathered. The trust had now moved to a new data base to ensure more accurate capture. The trust also advised that appraisals had moved to a window system, rather than fixed dates for all, which had also impacted compliance rates. Compliance with supervision and appraisal was also being monitored through a weekly director level huddle. We also heard how the trust was working to improve supervision and appraisal conversations to make these more meaningful. Following the inspection, we were told of improvements in the numbers of staff receiving supervision and appraisals. 

At the time of the inspection, the main concern from system partners across the trusts geography was the demand versus capacity for the adult and child mental health services. This was impacting on the numbers of people spending lengthy periods of time in the acute trust emergency departments. The trust had done extensive quality improvement work to look at how it could improve flow for people needing urgent care resulting in reductions in length of stay and a reduction in out of area placements (there were 3 people from Luton and Bedfordshire placed out of area at the time of the inspection). They had worked with acute hospital providers to ensure accurate data on wait times, train the workforce working in the emergency departments, and review policies for observation and the use of rapid tranquilisation. They had also developed some new services. For example, in Luton and Bedfordshire they introduced a mental health street triage service, an NHS 111 mental health crisis line, increased acute mental health adult bed capacity and opened a children and young people inpatient service. 

The trust was also aware of their other hot spots where people were waiting too long for a service. They had used quality improvement to reduce wait times for muscular skeletal services. This had led to several changes including strengthening the streaming process and offering digital self-management options. At the time of the inspection they were improving access to adult ADHD services. 

The trust continued to recognise the importance of maintaining the sexual safety of people using their services. The chief nurse was the lead for this work. The trust had worked to promote a trauma informed approach. Staff could access training on this on the trust website. The approach was also embedded into their trust wide work on therapeutic engagement. 

The trust had worked hard to develop and improve its digital offer. A digital strategy was in place. Recent achievements included joining up patient data with care partners; rolling out patient-held records in City Hackney and the move to digital Mental Health Act records and processes. The trust was ranked first in London and ninth nationally in the national digital maturity ranking. Since our last well led review improvements had been made to the trust’s digital infrastructure. WiFi access had also improved. Multi factor identification was in place for all system users. The trust was developing its cyber assurance framework and was data security and protection (DPSD) toolkit compliant. There had been significant improvements in the number of staff able to work remotely, up to 4,000 from a starting point of 400 in 2000. There were trust wide digital champions and people participation involvement. New Power BI dashboards and safety bundles were being developed for managers. 

The trust had appointed a guardian of safe working hours (GOSW). At the time of our review, they were not at work and interim arrangements were in place. The GOSW had most recently reported to board in December 2025. At that time, they reported some issues in data completeness, following the introduction of a new reporting system, gaps in rota coverage - with 401 vacant shifts requiring agency cover – some of which was attributable to strike action. Despite these pressures, the GOSW reported that minimum safe staffing levels were maintained and local escalation processes worked effectively. There were 81 exception reports in the period 1 October – 31 December 2025. Most were raised in London services and related to workload concerns within inpatient posts or out‑of‑hours shifts. There were 2 breaches of the junior doctor contract during this quarter, both of which resulted in fines. No work schedule reviews were completed during the reporting period. Work was taking place to support doctors to complete the reports in a timely manner, to improve data accuracy. 

The trust had developed and regularly reviewed its emergency planning and business continuity plan. This covered all areas of the trust’s resilience arrangements including incident response and surge management. Service-level business plans were in place to sustain essential mental health and community care provision during disruptions.

The trust managed complaints effectively. The complaints process was overseen and managed by a central complaints team. The investigation of complaints was led by appropriate locality managers with support from the central team. Information on how to complain was on the trust website. Information in relation to patient advice and liaison service (PALS) was also available on the trust website. During our service inspections, we saw that information on how to make a complaint was available locally. We met with the trust complaints team and reviewed 5 complaints. Where a formal complaint process was instigated, an investigator was allocated; terms of reference were agreed with the complainant; an investigation was completed; outcomes were conveyed to the complainant through a letter and, if appropriate, an action plan was developed. 

The complaints team reviewed investigation reports and response letters to complainants, which were authorised by the chief executive. Processes were in place to ensure learning from complaints was shared. The sample of complaint responses we looked at demonstrated the trust understood duty of candour and were open and honest with patients. The complaint investigations we saw were comprehensive and fully addressed the concerns raised. Complaint response letters contained sufficient information. Learning from complaints was incorporated into a variety of forums including the complaints team bi-monthly training programme, reporting at the patient safety forum and newsletters within each service. A people participation representative provided regular input to the complaints responses by reviewing drafts and providing recommendations.

During 2024-2025, the majority of complaints received related to attitude of staff, access to service, communication, clinical management and medication. Five-hundred and seventy-four formal complaints were raised in this period, a decrease of just over 10% compared with the previous year. Six-hundred and twelve complaints were closed, of which 320 were in agreed timescales. Two-hundred and forty-six complaints were closed outside of agreed timescales. Performance was affected in part by clearing a backlog of historical complaints. Report timeliness was being monitored with targeted support for services who were having delayed responses. 

Appropriate systems were in place to ensure new staff had the correct recruitment checks prior to working in the trust. Records were checked for staff who had recently joined the trust and all the necessary checks were in place. Systems were also in place to ensure medical, nursing and other professional registration revalidation had taken place for staff working in the trust. 

The trust board recognised the importance of partnership working. This included engaging with integrated care systems, place-based work including primary care, social care and third sector providers and provider collaboratives. Feedback from system partners noted that the current trust leadership was open and proactive at working with other stakeholders and providers, and a highly effective, trusted and system-focused partner. Partnership work led to innovation at place, meeting the needs of local populations. The trust continued to work in partnership with people who use services and people participation was embedded throughout the organisation.

The trust had maintained its active involvement in the 2 main care systems where the trust services were located. Executive directors were aligned to systems and taking leadership roles. They continued to work with the Bedfordshire Care Alliance where improved system working was enabling more people with long term conditions to receive the support needed to stay in their own homes. The trust continued to invite local commissioners to directorate management teams supporting collaborative working. 

The trust was involved in a number of provider collaboratives across its geography. These partnerships pool budgets and clinical resources across organisations to improve specialised mental health, community care, and patient pathways closer to home. The trust led on the North Central and East London (NCEL) child and adolescent mental health services (CAMHS) collaborative to manage adolescent inpatient mental health care for ages 13–18. The trust also partnered in the North East London (NEL) mental health, learning disability and autism collaborative; the East of England specialised mental health collaborative and the NEL community services collaborative. The integrated care sub committee of the board retained oversight of trust involvement in these collaboratives. 

There were section 75 National Health Services Act 2006 agreements in place with some local authorities within the trust and regular multi-agency meetings. Forums took place with partners including police and ambulance service. Feedback filtered through directorate management meetings. There were monthly meetings with the Approved Mental Health Professional (AMHP) service and separately, with lead independent MHA advocates (IMHA) for each directorate. Service level agreement (SLA) data was shared with acute partners quarterly. A recent refresh of some SLAs had taken place. Issues with receipt and acceptance of statutory MHA documents from acute partners were addressed during the refresh.

Robust arrangements were in place to safeguard adults and children. There was a clear governance structure for reporting to the trust board. Since the previous inspection adult and children safeguarding had integrated into a single team. Safeguarding matters were reported to a safeguarding committee, which in turn reported to the quality assurance committee and to board in an annual report. The chief nurse was the executive director for safeguarding. Named safeguarding leads were in place in each of the trust’s geographies. A central trust safeguarding team was able to advise staff in office hours. This team had been strengthened to include a data analyst to support early identification of themes or outliers. The safeguarding committee maintained a tracker to monitor the roll out of learning from safeguarding incidents. 

The trust was engaging with multiple agencies, maintaining representation on 5

safeguarding adult boards (SABs) and 6 safeguarding children partnerships (SCPs) 

across its operational footprint. At the time of our review the trust was participating in 11 safeguarding adult reviews, 10 domestic homicide reviews ,12 child safeguarding practice reviews, 4 learning reviews and 22 rapid reviews.

The safeguarding strategy was under review at the time of our inspection. The January 2026 report to subcommittee indicated that compliance with level 1 2 safeguarding training for both adults and children exceeded 90%. Children’s level 3 training also exceeded 90%, as did Prevent level 1 2 training. This same report to board indicated that staff vacancies had impacted upon the delivery of planned and ad hoc safeguarding supervisions. We were advised during the review that these posts had been filled and safeguarding supervision was now being delivered in line with trust guidance. 

The trust had place-based partnerships aligned to each of the London boroughs it operated in; Tower Hamlets, Newham City Hackney, and Luton and Bedfordshire These local partnerships brought together the NHS, councils, GPs, providers of health and social care services, the voluntary sector, people and communities, to agree what worked well and what was needed by local people. They also worked to tackle some of the wider things that can impact health, such as housing, employment, and poverty. 

The trust recognised that carers, friends and family have expertise and should be partners in the development of care alongside people using services and professionals. The trust had developed a carers, friends and family strategy. The strategy was co-designed and co-produced with carers and staff. It outlined 5 key priority areas and highlighted the requirement for local services to develop plans for how they would include and support carers, friends and family. 

People participation had become more embedded since the last inspection and was hard wired into how business was done at the trust. We heard of many examples where co-production was taking place and making a real difference to the experiences of people using services. People who use services were actively involved in key committees across the trust; were integral to the work on population health, collaboratively working to develop services to meet the needs of people in communities; were active participants in quality improvement initiatives in corporate services and in local services. This was in addition to the people participation work which had continued since the previous inspection including 63 peer support workers; 47 active befrienders supporting 177 people; and the ongoing service user led accreditation scheme. Patients and carers were proud of their work including a Parkinsons project led by service users managing their own care, with patient initiated follow ups, use of wearable digital monitoring devices and apps. They told us about involvement in patient led assessments of the care environment (PLACE), Academy of Lived Experience Innovation, being accessibility ambassadors, digital life coaches, guest lecturers, financial viability panel members, and governors.

We attended several people participation working together groups including the corporate working together group, and people participation committee. It was clear that patients and carers were involved in work at all levels in the trust including health and safety training, complaints responses, producing training videos and podcasts, staff recruitment and inspection of services. The trust was committed to improving routes to employment for patients and carers. We observed patients chairing groups, sponsoring projects, and active challenge from patients and carers passionate about their work. For example, patients and carers had been consulted about the trust strategy, but this was not available in an easy read format at the time of the launch. Patient participation leads valued opportunities for autonomy and creativity in their roles but wanted clearer structures, and training to support them, including reflective practice sessions. Trust leaders were aware of these issues and arranging for a cultural review to be carried out for the service. 

Partnership working to meet the needs of local populations and improve health outcomes and inequalities had developed further since the last inspection with the focus on population health. We heard about the continued active participation and leadership roles by members of the trust leadership team in the 2 care systems where most trust services were located. Feedback from partners highlighted trust strengths in people participation and cultural competence in the communities they served. There was good collaboration and partnership working to ensure medicines information was shared with services both internal and external. The chief pharmacist chaired an integrated care board medicines value group. Collaborative initiatives included shared pharmacy training opportunities with acute providers, technician placements within community pharmacy and reciprocal training arrangements supporting prescribing development. 

The trust had many examples of where it was working in boroughs and neighbourhoods to meet the needs of communities. For example, in Tower Hamlets, the trust had opened Barnsley Street, a pilot site offering 24/7 open access neighbourhood mental health centre. Another example was the healthier, wealthier families initiative in Newham and Luton helping homeless people open bank accounts, supporting people to receive specialist immigration advice and providing learning for young people to improve their financial awareness. This was being implemented in partnership with local councils, Citizens Advice and banks. In Bedfordshire the trust was working with district nurses to identify unpaid carers, including training for GPs, and publicity on the local hospital radio. Financial decisions had led to some concerns from partners for example reduction in the opening hours of the crisis café, and access to interpreters in Bedfordshire.

People in Bedford struggling with substance misuse were being supported by an innovative GP and addiction service partnership. ELFT’s path 2 recovery (P2R) substance misuse service team had linked with specific primary care providers to develop an addiction model of care that supported safer prescribing in primary care and identified people dependent on prescribed medication who would benefit from formal treatment from P2R. The programme was well received when presented at the Royal College of General Practitioners annual conference. The model was in the process of being rolled out to other GP practices. Identified benefits of the approach included; dramatically improved patient attendance; a supportive approach, maintaining patient dignity and choices; high success rates in medication reduction and prevention of new high-dose opiate prescriptions.

Learning, improvement and innovation was an area of particular strength for the trust. There was a well-established research programme engaging staff from a range of professional backgrounds. Research and quality improvement were embedded in co-production with people who use the trusts services and their carers. The trust had progressed from piloting the Patient Carer Race Equality Framework, with noticeable improvements for global majority service users.

Quality improvement (QI) continued to be a strength for the trust. It was seen as a key driver to developing and embedding a culture of continuous improvement and learning across the organisation. During our core service inspections and well led review we saw how operational and corporate QI projects were being extensively used. Some projects were local to specific teams or services, others had been scaled and were being tested trusted wide. The trust had a dedicated QI micro website that staff could access. A range of key training was available to support staff in engaging with QI. This included foundation ‘pocket’ QI, an improvement leaders programme and an improvement coaching programme. People who use services and their carers were also encouraged and supported to engage with QI and a training programme was available specifically for them. We saw evidence of co-produced QI programmes during our review. The trust were proud to have contributed to the wider knowledge base underpinning QI across different healthcare fields through the publication of their work in several peer reviewed journals.

At the time of the inspection there were 178 live projects. We heard how QI had supported numerous trust wide improvements. These included improving the flow of mental health patients across the trust and reducing out of area care; and improving waiting lists for services for example in musculoskeletal services. We also observed how a trust wide quality improvement project was improving therapeutic engagement on inpatient wards. This project, aimed to transform staff interactions with patients from observing to interacting. It had been rolled out to 21 wards at the time of the inspection, with a plan for all wards to use this methodology by December 2026. The first phase reduced enhanced observations by 49%, without increasing physical violence, self-harm or use of seclusion on the wards. A ‘care that counts bundle’ was put in place to increase staff confidence, anticipation of patient individual needs, and engagement with patients and relatives. Interventions included use of a ‘feelings thermometer’ for patients, protected engagement time and flashcards. 

Other quality improvement projects included reducing missed foot health appointments amongst homeless people, and cervical smear appointments amongst sex workers, including changes to times and facilities provided. The Tower Hamlets Continence service had improved attendance from 35% to 90% for Bengali women. Although Luton and Bedfordshire had been slower to implement quality improvement techniques, there were significant results to be seen. There was a 75% decrease in out of area mental health placements, 67% increase in access for global majority service users to the perinatal service, and 104% increase in patients seen within 18 weeks for the chronic fatigue service.

The trusts well established research function also continued to be a strength. They aimed for researchers to work with and in support of, the continuous improvement of services. A service user led participation and research collaborative had been developed with a neighbouring trust with the aim of bringing together people with lived experience to shape and inform research. The trust conducted approximately 30 studies each year, governed by a research committee. At the time of our review 13 studies were actively recruiting within the trust. These included; clozapine in early psychosis; real world dementia outcomes and improving quality of life in people with intellectual disability. Other studies recently supported by the research unit included; understanding sexual behaviour in forensic units, ‘Flipping Pain,’ a project aimed at understanding unexplained physical symptoms in school children, and research into a blood test for dementia. An air filtration unit had been piloted on an inpatient unit in Bedfordshire contributing to reduced staff and patient sickness. 

The trust was responsible for developing the Dialogue Plus tool to monitor patients’ quality of life, which had been rolled out across a number of different NHS trusts. They were working on a Trialogue staff facing tool to support staff to address bullying and harassment during supervision meetings. The trust hosted an annual conference showcasing research and innovation. The trust was working with a range of academic institutions including Queen Mary’s, University of Cambridge and University College London. 

An impressive research hub had been opened in Luton since our last review. This was supporting research into a range of population health outcomes for physical and mental health in children, young people and adults. The research undertaken had resulted in improvements for people using services and supported the development of communities of practice for professionals. The hub had supported local teams to design, test and embed evidence-based improvements, addressing physical, psychological and social factors. These new models of care addressed: population health risk stratification in primary care; cardiovascular inequalities; menopause and mental health; children and young people’s mental health in refugee and asylum seeking populations; engaging mind body approaches in young people with persistent symptoms and reconfiguring inclusive access through a community care model for children.

The trust continued to implement the Patient and Carer Race Equality Framework (PCREF, begun in 2021) in partnership with local statutory and voluntary services and taking account of the Denny Review of 2023 into health inequalities across Bedfordshire, Luton and Milton Keynes. The trust had a deliberately small equality, diversity, and inclusion team aiming to ensure that all trust staff worked with diverse and minoritised communities to coproduce and implement the PCREF into standard practice. Clear deliverables were identified, including targets for staff training, and use of quality improvement methodology to improve outcomes for disadvantaged groups. A series of workshops ensured people who used services and their carers co-produced projects within the framework. Three teams had presented their work internationally. Examples of successes included a reduction in racist incidents in forensic services, increasing psychology access for patients experiencing early episode psychosis identifying as global majority and reducing missed appointments for the most deprived populations. They had also introduced faith-adapted psychological therapy for patients of Bangladeshi and Pakistani ethnicities. The trust was also working in partnership with 2 other London trusts to explore PCREF in the context of the use of force. 

At the time of our review directorates were being asked to develop PCREF plans for individual teams and wards with a focus on developing and embedding trauma informed care and cultural competence. Outcomes were being measured to see if improvements were delivered including; reducing the use of restrictive interventions for global majority patients and the length of time global majority service users were subject to community treatment orders. A trust wide dashboard to strengthen reporting and oversight of PCREF was also in development. 

A number of teams had achieved Royal College of Psychiatrists College Centre for Quality Improvement accreditation (RCPsych CCQI). At the time of our review, 15 wards and teams had achieved accreditation, with others undergoing assessment. 

The trust had been nominated for and had won in excess of 30 awards in 2025/2026. These included; Staff and service users from the John Howard Centre won the HSJ Digital Award for ‘Empowering Patients Through Digital’ 2026 for their co-designed Pathways App. They were finalists in 2025 for ‘The Healthier Wealthier Families Programme’. The trust Path to Recovery (P2R) Addictions Service and Bedford Hospital won a joint national award in 2025 for their collaborative clinic addressing alcohol-related liver disease. The trust’s chief quality officer had been awarded the RCPsych Awards, President’s Medal. 

The trust was working to understand the negative impact of its activities on the environment and was striving to make a positive contribution in reducing this and supporting people to do the same.

The trust had clear goals in relation to sustainability. These were outlined in the trusts recently refreshed green plan. A steering group fed into various work streams to ensure green plan aims and targets were considered. Two leads had been funded to work across the trust to work on promoting the green plan and monitoring its delivery. They also promoted the sustainability agenda more generally across the trust and encouraged other staff to engage with the trusts green plan and make sustainability everyone’s business. 

The board had approved and were sighted on the refresh of the green plan. They received regular reports on progress. Using the going further, going together programme, the trust aimed to make savings in excess of £200,000 as part of its sustainability programmes. Sustainability initiatives in progress at the time of our inspection included work to reduce polypharmacy on older peoples wards and the return of unused walking aids. The trust worked closely with partners, for example, at the Homerton acute hospital, where plans were underway to introduce a green corridor.

The trust had developed a decarbonisation strategy. There were multiple workstreams within the trust focusing on how carbon use could be reduced. One QI project was looking at how the carbon footprint related to transporting medicines to different sites could be reduced. The pharmacy service was working towards green pharmacy accreditation. 

The trust had been successful in bids to install solar panels at the Newham Centre for Mental Health and at the John Howard Centre. The Newham project had a potential 20 year saving of £1.82 million, while the John Howard Centre project had a potential 20 year saving of £1.75 million. 

As part of the green plan, a trust wide green space improvement group was working to improve therapeutic green space across sites to boost mental and physical wellbeing. Projects included the hope garden in Newham, rewilding initiatives, and nature-inspired programmes with the London Wildlife Trust.

Education materials and voluntary training in relation to sustainability was available for all staff. The trusts green plan was addressed during induction and dedicated sustainability information was available on its staff intranet pages.