Cumbria, Northumberland, Tyne and Wear 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 clear, shared vision and strategy focused on transparency, equity, human rights, diversity, inclusion, and meeting the needs of its local communities. The Trust’s transformation programme was ambitious and had achieved some key milestones. However, some fundamental patient safety issues had not been addressed promptly, suggesting that the focus on innovation and transformation may have overshadowed essential quality and safety priorities. Despite this strategic clarity, the culture within some areas of the trust was poor. Staff concerns indicated that the values set out in the strategy were not always reflected in day-to-day practice.

In assessing this quality statement, we considered feedback from leaders, staff, people using services and local system partners, as well as reviewing trust processes and survey results. The trust’s strategy, vision, and values launched in May 2023 as “with you in mind”. They were developed through engagement with staff, service users, carers, and partners. The vision centred on compassionate, lifelong care, and the values emphasised respect, honesty, and sustainability.

The trust’s vision was “to work together, with compassion and care, to keep you well over the whole of your life”. With values which are:

• caring and compassionate: treating others as we’d want those we love to be treated.
• respectful: everyone is of equal value, entitled to dignity and equal rights.
• honest and transparent: fair, open, and helping people make informed decisions.
• protecting rights and the planet: committed to future generations and sustainability.

The trust strategy set out 5 ambitions:

• quality care, every day: deliver expert, compassionate, person-led care in every team, every day.
• person-led care, when and where it is needed: support changing needs over people’s whole lives, working with partners and communities.
• a great place to work: ensure the workforce has the right values, skills, diversity, and experience.
• sustainable for the long term, innovating every day: be a sustainable, high-performing, digitally enabled organisation.
• working with and for our communities: build trusted, long-term partnerships to help people and communities thrive.

The strategy was described as a “living document,” designed to evolve in response to ongoing feedback.
The trust told us that when their strategy was launched in 2023, they made the decision not to have enabling strategies but to have a single trust strategy underpinned by annual priorities to enable delivery. Where there was a need for a wider strategy (such as for physical health) they had been developed but each strategic ambition had a delivery plan or similar associated with it, these were noted as:

• workforce
• estates
• green plan
• digital
• risk management
• quality priorities
• physical health
• together strategy

The trust also told us that following publication of the NHS long term plan and forthcoming long-term workforce plan they agreed to develop a people strategy which was currently moving through engagement processes.

The trust’s ability to measure success against its strategic objectives were outlined in their board assurance framework (BAF). The highest rated risks were noted as CQC compliance, access and performance, patient safety culture, workforce sustainability, and financial sustainability. Moderate risks included transformation/model of care, staff motivation and wellbeing, estates infrastructure, and digital/cyber threats. Risks were reviewed regularly, with most reviewed between June and September 2025. Each risk was assigned for oversight and management to an executive board member and to the responsibility of a sub-committee of the board.

Key to delivery of their strategic ambitions was the trust’s ability to deliver their revised model of care and support. There was a programme of five key elements of change overseen by a single transformation board, the ‘model of care programme board’.

Understanding and prevention: Developing neighbourhood health models, including Hope Haven, one of six national 24/7 mental health centres.

• Community treatment: Expanding community-based care to support people outside hospitals.
• Long-term complex needs: Providing sustained, assertive care for severe mental illness, moving away from episodic support.
• Urgent and crisis care: Improving crisis response, safety planning, and access, aiming to reduce self-harm, suicide, and readmissions, with tailored support for autism and complex needs.

• Inpatient care: Focusing on person-centred, therapeutic treatment, early discharge planning, and reducing restrictive practices, with ongoing ward redevelopment and partnership work.

  The programme board met regularly, with sub-groups managing workstreams such as:

• Front door and prevention: Shifting to personalised, keyworker-led care, digital tools, and community hubs.
• Community treatment: Workforce planning, improved access, expanded therapies, and better transitions.
• Severe mental illness and complex needs: Intensive support for those with complex needs.
• Urgent care and crisis: Hospital-to-home models and enhanced crisis triage.
• Inpatient care: Redeveloping wards, enhancing rehabilitation, and new clinical models.

Whilst the transformation programme would enable the trust to achieve its strategic ambitions, there appeared to be a lack of clarity between operational and strategic risk management. While the Trust had a comprehensive risk management framework, there remained a gap between strategic risk oversight through the Board Assurance Framework (BAF) and operational risk management via the Corporate Risk Register (CRR). The BAF provided clear visibility of the Trust’s principal risks, which remained above the stated risk appetite, and demonstrated appropriate governance, review, and assurance processes. However, the persistence of these risks over time suggested that while risks were identified and monitored, there was less evidence that mitigating actions were consistently translating into measurable risk reduction at operational level.

The CRR contained a large volume of risks, which may dilute focus on the specific operational drivers underpinning BAF risks. This weakened the thread between frontline controls, care‑group delivery, and strategic assurance, creating a position where risks are known, accepted, and reviewed, but not always demonstrably reduced.

Strengthening the alignment between BAF risks and the specific, outcome‑focused actions within the CRR would provide greater assurance that risk management activity was leading to tangible improvements in safety and quality.

The trust commissioned an external review of strategic embeddedness in 2024. The review found that there was a high awareness of the strategy with positive cultural alignment. However, the review suggested that the strategy lacked measurable deliverables and clear links to annual planning with pockets of poor culture in some localities (particularly in west Cumbria). The review made recommendations for the trust to develop supporting strategies (clinical, digital, workforce) and to articulate how it meets strategic milestones to enhance oversight of strategic delivery.

The trusts medicines optimisation strategy was supported by an action orientated plan. This was reviewed through medicines governance channels and was aligned to the trust’s strategic aims.

Culture
Executive leaders demonstrated their commitment to compassionate and inclusive leadership. They were positive about the trust’s culture and aware of the work required to make improvements. However, data and staff narrative highlighted the need for leadership to focus on rebuilding engagement, recognition, inclusion, and staff voice at all levels.

The NHS Staff Survey provides insights into staff engagement, morale, and workplace experience. In 2024 CNTW had 3,354 completed questionnaires with a response rate of 42%, which was lower than
the national rate of 54%.

The 2024 survey provided evidence that staff engagement and morale had both declined since 2020 and are now just below the national average for similar trusts. The trust score was significantly lower when compared to 2023 results for the following elements of the survey:

• we are compassionate and inclusive
• we are recognised and rewarded
• we each have a voice that counts
• we are a team
• staff engagement

Key sub-themes such as; motivation, involvement and advocacy all show a downward trend. Fewer staff reported looking forward to work, feeling enthusiastic, or feeling able to make improvements in their area. Morale was lower, with more staff thinking about leaving, feeling work pressure, and experiencing stressors.
Scores for “We are compassionate and inclusive” and related sub-themes (compassionate culture, leadership, diversity, inclusion) have declined since 2022. The trust was previously above average for compassionate leadership but is now slightly below the national average. Significant reductions were seen in recognition and reward, having a voice that counts, and teamwork. Staff felt less recognised, less able to influence decisions, and less positive about teamworking than in previous years.

One area with notable improvement was in appraisals (within “we are always learning”), which had steadily increased since 2021.

The trust’s score for “we are learning” was slightly higher than the national average.

Fewer staff felt able to raise concerns or advocate for the trust as a place to work or for care. The “raising concerns” score had reduced, and fewer staff would recommend CNTW as a place to work or receive care. Between October 2024 and October 2025, CQC had received 120 concerns from staff. 96 of these were received following a letter we sent to staff asking them to share their feedback to support our assessment. The feedback we received was mainly negative. Staff reported unsafe staffing levels, heavy reliance on agency staff, and frequent redeployment without consultation, they told us this led to increased risks, burnout, and compromised safe care. Some staff highlighted unsafe physical environments, especially at the Campus for Ageing and Vitality, with staff feeling unsafe, particularly after dark. Concerns were raised about inadequate training, lack of supervision, and unqualified staff performing tasks beyond their competence. There was a perceived disconnect between senior leadership and frontline staff, with decisions made top-down and staff feeling unsupported and unheard. Reports described bullying, intimidation, and a culture of fear, resulting in low morale, high sickness rates, and distress over not meeting care standards. Allied health professionals felt devalued and underrepresented.

We also received some positive feedback which included that despite systemic issues, some staff reported strong support from immediate managers and teams, good local leadership, and a commitment to patient care at the ground level. Staff gave examples of innovative practice, compassionate team leadership, and positive patient and carer feedback in some areas.

Staff we spoke with during focus groups gave feedback about the approach of leaders. They described their immediate managers and team leaders as approachable, compassionate, and supportive, especially regarding induction, training, and wellbeing. Staff in some teams felt valued and appreciated, with managers who fostered open communication and encouraged speaking up about safety. Some staff and staff networks reported that executive leaders, including the chief executive and board members, were visible, approachable, and receptive to feedback, particularly through direct visits, open channels of communication, and engagement with staff networks.
However, staff also described a disconnect, staff felt there was a significant gap between senior leadership and those delivering care. Decisions were often perceived as top-down, with limited consultation or understanding of frontline realities. Some described a “them and us” culture, especially since the pandemic, with senior leaders being less visible and more remote.

Staff frequently reported that the quality of leadership and support varied greatly depending on the team or service. While some managers were described as compassionate and effective, others were seen as unsupportive, dismissive, or even fostering favouritism and a lack of accountability. Some staff described a culture of fear around disciplinary processes, with “fact finds” seen as interrogative and punitive rather than supportive or focused on learning.

Staff highlighted inconsistent or delayed communication from leaders, especially regarding changes, policies, or incidents. Some felt information was not cascaded effectively, particularly through middle management.
Leaders were seen as constrained by financial challenges, which impacted staffing, training, and career progression. Some staff felt leaders were open about these pressures, while others felt decisions were made without sufficient transparency or frontline input.

Despite challenges, there were examples of positive, inclusive leadership and supportive cultures in certain teams and services. The chief executive officer (CEO) acknowledged that poor culture could develop over time and was committed to open conversations to manage staff experiences with sensitivity.

To make cultural improvements the trust had invested in a leadership development academy. The leadership programme was being delivered to all staff at band 7 and above, it was led directly by executives, with 150 people having completed it and a goal to reach all eligible staff by March 2026. The aim was to embed leadership skills and support a compassionate, values-driven culture.

People we spoke with told us about the positive impact of the academy and leadership development on staff morale, succession planning, and the ability to respond to challenges.

Stakeholder feedback described CNTW as a trust with a strong, values-led culture, committed to partnership, inclusion, and continuous improvement. Leadership was described as accessible and effective, and the organisation was praised for its openness, innovation, and collaborative approach.

The trust have inclusive leaders who understand the context in which they deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively. They do so with integrity, openness and honesty.

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.

The chief executive officer (CEO) had worked at the organisation for more than 20 years and had been in post as CEO since 2022. Our discussions and observations demonstrated a leader with deep commitment to values-driven transformation, who continued to lead the trust through significant challenges and change. A considerable amount of work had gone into strengthening governance and risk management across the trust with a focus on clarifying where responsibility was held. While progress has been made, the CEO acknowledged that the journey was ongoing.
The trust chair had been in post since October 2023. They brought thirty years of experience in the police, including a decade in senior executive roles and as a previous non-executive director they brought operational and strategic insight to the board. The chair was passionate about setting and strengthening the culture of the organisation, believing that accountability and performance must be visible to those served by the trust. A strong advocate for staff engagement, the chair paid close attention to staff survey response rates.

The executive leadership team worked in a triumvirate model with an executive medical director, executive director of nursing and therapies and a chief operating officer. This leadership structure was modelled through each care group. All 3 leaders described collective and collaborative leadership, with a relentless focus on quality and safety, and a deep commitment to staff development and engagement. All 3 leaders valued the importance of working together as a triumvirate, ensuring that decisions were made with input from multiple perspectives and that oversight of quality, safety, and people was robust and shared. They highlighted the value of expert staff, the need for clear governance structures, and the importance of adapting to change whether in response to inspections, system pressures, or evolving workforce needs. The team demonstrated a passion for their teams and a commitment to fostering a culture where clinical voices were heard, risks were managed proactively, and continuous improvement was at the forefront of organisational priorities.

We observed the trust’s board meetings and attended several governance and committee meetings. We observed leaders acting with integrity, credibility and kindness. The trust actively supported diverse communication needs and ensured meetings were accessible.

Leaders undertook regular visits to frontline services. These visits improved leadership visibility and ensured leaders were able to triangulate the information received through the trust’s governance systems, particularly in relation to staff experience. Between March 2024 and July 2025, more than 80 structured visits were undertaken by the chief executive, non-executive directors, governors, and executive directors, covering a broad spectrum of services including inpatient wards, community teams, specialist units, and digital services. The programme reflected a consistent pattern of engagement, with visits occurring monthly across different localities and care groups.
Governors and non executive directors completed reports shared with the board following visits.

Service visit reports highlighted strong staff morale, teamwork, and commitment to high-quality care across teams, with positive service user experiences and recognition for innovation in areas like digital services. However, significant challenges remained, including workforce shortages (especially in specialist areas), high sickness rates, reliance on temporary staff, increased demand and long waiting lists, and delays in discharge due to limited community placements. Environmental concerns, facility upgrades, and systemic issues such as integration with social care and operational pressures were also noted, with some teams reporting a lack of autonomy and high administrative burdens.

For the chief pharmacist and medicines optimisation service there were clear lines of accountability, through the trust’s governance structure. Visibility of leadership was described as integral with several strategies in place to ensure all staff including those at remote sites were regularly able to meet with the pharmacy leadership team.

Staff network representatives described the attitude and approach of senior leaders as supportive and engaged, particularly at the executive level. Leaders were recognised for embracing staff networks, providing administrative support, and responding promptly to urgent issues, such as requests for statements or safe spaces following incidents. However, concerns were raised about the consistency of this support, with some staff noting that positive engagement from executives did not always filter down to middle management, resulting in varied experiences across teams.

Staff-side (union) representatives described positive working relationships with leaders; highlighting open communication, regular partnership meetings, and successful collaboration on issues such as Disclosure and Barring Service charges, parking, and mileage. However, they also raised concerns about staffing shortages, high agency use, and the risk of losing international staff due to visa issues. Outsourcing of services and inconsistent communication were ongoing frustrations. Health and safety processes were praised but challenges remained in services with high levels of violence towards staff and in ensuring consistent application of policies such as sickness and bereavement leave.

There was a mixed view of the support received from executives from freedom to speak up guardians (FSUG). They told us about good support from the chair and executive director of workforce who were described as approachable and understanding. But shared a perception that many managers, especially at middle management level, did not value or fully understand the importance of the FSUG role. They told us that issues that reached higher levels of management were often resolved quickly, but many concerns get “stuck” at middle management level and are not escalated or addressed promptly.

The trust had processes to identify and address behaviours that were inconsistent with the values of the NHS. Between 1 July 2024 and 1 July 2025, there had been 107 disciplinary cases and 8 grievances raised within the trust. The processes were undertaken thoroughly but were not always completed in a timely manner. Staff we spoke with did not feel comfortable with the processes.

Of the disciplinary cases, 57 cases had been completed, 49 were ongoing and the oldest ongoing case was from August 2024. Eighty-two cases had been brought against staff who identified as white, 23 had been brought against staff who were not white and 2 did not have their ethnicities stated.

Of the grievance cases, 2 had been completed, 8 were ongoing and the oldest open date was September 2024. All staff who brought grievances identified as white other than 1 staff member. Only 1 of these cases were noted to be related to bullying and/or harassment. This is a low figure for a staff team of this size and may indicate a concern about cultures and freedom to speak up.

The most frequent disciplinary cases at the trust involved inappropriate behaviour towards colleagues, breaches of observation protocols, criminal convictions, inappropriate behaviour towards patients, neglect of duty, improper access to patient records, unprofessional conduct, boundary breaches, inappropriate use of physical intervention, and alcohol or substance misuse. Grievances most often related to pay and departmental processes, bullying and harassment, colleague behaviour, and discrimination or lack of support. The services most commonly involved were adult community mental health, autism wards, adult acute wards, children and young people’s inpatient and community services at Ferndene, inpatient rehabilitation, and access and treatment teams.

The trust disciplinary policy (August 2024) set out clear standards of conduct for all employees and provided a framework for addressing concerns about behaviour. The policy emphasised early, informal resolution of issues wherever possible, with formal procedures reserved for persistent or serious breaches.

The process included informal management, fact-finding investigations, and where necessary, formal hearings. Disciplinary sanctions ranged from written warnings to dismissal, with the right of appeal at each stage.
We reviewed 7 examples of disciplinary cases, and all had been completed in line with the trust’s process although 3 of these cases took considerable time to be resolved (between 3 and 6 months). The trust’s target for disciplinary cases was 56 days to hearing. Of the 57 completed cases in the data provided by the trust the quickest resolution was 3 days with the longest 322 days, 32 cases took longer than 56 days to resolve.

We reviewed 3 examples of grievance cases, 1 had been withdrawn, and the remaining 2 cases had been undertaken in line with trust policy however the cases took considerable time to be resolved (between 10 and 20 months). The trust policy did not set out clear time limits for resolution of grievances but described they should be handled without delay.

The trust had a resolution policy which replaced the grievance policy and was introduced in February 2025. The policy applied to all trust employees and prioritised early, informal resolution of concerns. Grievance and disciplinary cases were overseen by a triage decision making group. The group met weekly and was made up of the care group nurse director and head of workforce and organisational development, as well as a senior member of the workforce and employee relations team. Where possible concerns were resolved quickly and informally as a method of reducing the stress and costs associated with long term cases. Since the policy was updated in February 2025, the triage group had heard 18 resolution requests in replacement of formal grievance processes. In these cases, 8 were resolved at the early resolution stage, 4 were ongoing in early resolution and 6 had proceeded to the early resolution stage. Between 1 April and 30 September 2025 the triage group had reviewed 135 disciplinary cases and 50% of these had received an informal outcome.

At the time of the inspection, the trust had ten ongoing employment tribunal cases involving claims of discrimination, harassment, unfair dismissal, victimisation, and whistleblowing. The cases covered a range of staff roles and included allegations related to race, sexual orientation, religion, disability, and sex discrimination.

Stakeholder feedback demonstrated that partners viewed the board and senior leaders as
experienced, capable, and values-driven, with a strong commitment to openness, integrity, and collaborative working. Leaders were described as accessible, inclusive, and forward-thinking, setting a positive culture. Partners shared examples of positive partnership working, highlighting proactive, co-operative relationships with individual leaders and joint achievements in areas such as integrated crisis support, the Hope Haven project, and joint scoping of mental health priorities.

There was evidence that leaders were visible both within services and across the wider local system, regularly engaging at strategic and operational levels through multi-agency meetings, management forums, and partnership boards. The trust was recognised as an active and constructive member of the integrated care system participating in system-level groups and provider collaboratives, and contributing to joint quality forums, strategic planning, and operational pilots.

The board were a stable and experienced team. The trust’s board comprised of the chair and chief executive and five executive directors including the chief operating officer, executive medical director (deputy chief executive) interim executive director of finance, executive director of nursing, therapies and quality assurance and executive director of workforce and organisational development. There was also a director of communications and corporate affairs.

The trust had a group of non-executive directors who chaired the sub committees of the board including quality and performance, mental health act legislation, people, resource business and assurance, audit, renumeration and charitable funds. At the time of the inspection there were some ongoing changes in the non-executive director team with several relatively new team members being recently recruited.

There was a board development plan in place.

In 2024 the trust commissioned reviews of board, committee and executive effectiveness. These reviews were undertaken 12 months after the trust launched their strategy and following a period of organisational restructure. The reviews found that in board and committee effectiveness there was positive progress with improved diversity, enhanced focus on governance and positive board development activities. There were recommendations to improve report quality to board to focus on assurance, strengthen levels of challenge and accountability and streamline committees which were noted as having busy agendas and duplicate reporting. Reviews discussed a commitment to cross sector working and to reach strategic objectives by executives. It recommended improvements in portfolios with some overlap of job roles and unclear accountability.

The trust had a fit and proper persons policy and process in place which outlined a framework for inclusion in the checks, this framework included 22 senior leaders and 4 directors from NTW solutions. An audit of the trust’s process was given substantial assurance for 24-25. In June 2025 the trust submitted the annual fit and proper persons test report to the board. The report provided full assurance that the Board of Directors and those with “Director” in their title met the requirements for 2024/25. The report showed that four directors had outstanding DBS checks, however this was being acted upon at the time of our assessment. All files we reviewed showed the trust had mainly completed appropriate checks of directors’ suitability for their roles. All directors had received an annual appraisal within the previous year other than one individual who was leaving the trust at the time of the assessment. Of the six files we reviewed we noted that one director did not have references located on their file.

The trust also undertook social media screening checks annually for board members and this was noted on fit and proper persons checks.

The evidence that we reviewed did not always demonstrate an open culture in which staff felt able to raise concerns, report incidents and suggest improvements. There was fear of detriment, staff were not always confident that their feedback, suggestions and concerns would be welcomed and lead to improvements in the trust.

In assessing this Quality Statement, we considered feedback from leaders and staff as well as reviewing trust processes and survey results.

Executive leaders role-modelled good speaking up behaviours, they listened to staff feedback and concerns, they demonstrated candour and empathy when things went wrong.

Two freedom to speak up reports were submitted to the board in the last 12 months; in December 2024 and July 2025. In the period from April to September 2024, a total of 39 concerns were raised, with the majority (36) reported via the freedom to speak up guardian, 2 via CQC, and 1 directly to workforce. This represented a decrease from the previous period. The most common themes were management processes and behaviour, including issues such as lack of support and bullying. From October 2024 to March 2025, the number of concerns increased to 65 (59 via freedom to speak up) and 6 via CQC, which is consistent with the same period in the previous year. Bullying emerged as the most frequently cited issue, followed by concerns about management processes and safety.
Concerns were raised across a range of areas, with community and inpatient services accounting for the highest numbers.

Data from staff surveys provided further insight into the trust’s speak up culture. The bullying survey conducted in August to September 2024 found that 36% of respondents had experienced bullying in the previous 6 months, but only 22% had reported the incident. Barriers to reporting included fear of repercussions, lack of trust in confidentiality, and a belief that nothing would change. The July 2024 quarterly pulse survey indicated that while most staff feel empowered to speak up, a significant minority remained hesitant due to similar concerns. The survey noted that 24% of respondents were unaware of external avenues for raising concerns.

There were 3 freedom to speak up guardians, and the trust stated in the July 2025 board paper that the speaking up process had been strengthened with monthly meetings between workforce and freedom to speak up guardians. These meetings were to ensure that timely action was taken for concerns
raised. There were 37 freedom to speak up champions.

National data showed that between April 2024 and March 2025, staff raised 64 concerns with their freedom to speak up guardians. When comparing CNTW to 7 other NHS trusts in the North East and Yorkshire of a similar size (each with more than 10,000 employees), the number of concerns raised at CNTW is low. For context, 1 of these trusts had 271 cases reported, while another had just 60.

Staff we spoke with did not always feel safe to raise concerns and challenge unsafe practice. Speak up guardians described a role that had struggled to maintain momentum over recent years, with limited proactive engagement and underutilisation of the champions across the trust. While some progress had been made in establishing policies and procedures, they described that the service remained reactive, and champions’ involvement as minimal beyond basic visibility measures such as email signatures. Training sessions were planned to reinvigorate the network, and there was a clear aspiration to involve managers as champions to strengthen cultural buy-in. They told us that support from senior leaders was acknowledged as positive. However, engagement from middle management was less responsive.

We spoke with a range of staff in focus groups and several staff shared their feedback through our online experience form. We heard that awareness of freedom to speak up varied. Some staff did not know the process existed, while others had used it but did not receive feedback or see outcomes. Staff described barriers to speaking up which included fear of retaliation, lack of confidentiality, and concerns about career impact (especially for staff on visas or from minority backgrounds). Some staff reported that concerns were referred back to managers and not addressed or that speak up concerns sometimes became investigations, or fact finds for people processes which made them reluctant to use the process.

Some positive examples were shared and staff told us that where the process worked well it was due to supportive local managers or networks. There was recognition that recent efforts had increased promotion and awareness.
The pharmacy team were supported to speak up and had embedded a freedom to speak up champion at each of their four department bases. Staff were encouraged to report incidents, and we could see from incident data that there was a positive culture of incident reporting.

Between October 2024 and October 2025, CQC had received 120 concerns from staff. 96 of these cases were received following a letter we sent to staff asking them to share their feedback to support our assessment. The feedback we received about the freedom to speak up process was mainly negative. Staff reported barriers to speaking up citing fear of retaliation, lack of confidentiality, and previous negative experiences with the process. Some reported that concerns were ignored, dismissed, covered up or lead to negative consequences for the complainant. There were reports that staff were told what to say to CQC inspectors, that feedback mechanisms were performative, and that whistleblowers were isolated or pressured to leave.

The trust was proactive in its approach to workforce equality, diversity and inclusion, with clear accountability, and a willingness to learn and improve with clear plans in place to increase staff experiences and truly embed equality, diversity and become an inclusive workplace. However, whilst we saw improvements in board and workforce diversity metrics showed that some staff continued to experience disadvantages while working at the trust. Improvement to these metrics is key to meeting the trust’s strategic objective to be a ‘great place to work’.

As part of the NHS Staff Survey, the workforce race equality standard (WRES) highlights potential differences between the experiences of white staff and staff from ethnic minority groups. Much like the WRES, the workforce disability equality standard (WDES) allows NHS trusts to compare the experiences of staff with a disability, a long-term condition and other types of illnesses, with those of non-disabled staff.

At the trust, people from ethnic minority groups made up 13% of the workforce (up from 11% in 2024), higher than the regional population average of 7%. Fifty-two% of medical staff were from a minority ethnic group background. Board representation was relatively strong, with 14% of board members identifying as from a minority ethnic group, compared to 13% of the overall workforce. Board representation for disabled staff was 7%, compared to 10% of the overall workforce.

In the workforce race equality standard, most indicators got worse for minority ethnic staff between 2023 and 2024, especially around bullying, harassment, and discrimination. Disabled staff also reported worse experiences in 2024 than in 2023, particularly regarding bullying, harassment, and feeling valued. Some improvements were seen in representation, but overall, the experience gap had widened.
The results of the 2024 NHS Staff Survey were worse for staff from all other ethnic groups at the trust when compared to white staff for all four metrics, indicating these staff experienced more instances of discrimination, harassment, bullying or abuse, and a lesser sense of equal opportunities within the trust.

Key aspects were reported as:

• White applicants were currently 2.24 times more likely to be appointed from shortlisting than minority ethnic applicants, and this gap had widened.
• Staff from minority ethnic groups were 1.69 times more likely to enter formal disciplinary processes than White staff, which represented a slight improvement.
• Bullying and harassment remained significant issues, with 48% of minority ethnic staff reporting such experiences from patients or the public (a gap that had doubled) and 24% reporting it from other staff, though this gap had narrowed.
• In terms of career progression, 56% of staff from minority ethnic groups believed there were equal opportunities, and this gap was closing. However, 18% of staff from minority ethnic groups reported

Almost 10% of staff at the trust declared a disability, an increase from 9%, though the NHS staff survey indicated that 37% of staff live with a long-term condition.

• In recruitment, non-disabled staff were 1.4 times more likely to be appointed from shortlisting, a trend that remained unchanged.
• Bullying and harassment were ongoing concerns, with 29% of disabled staff reporting these experiences from patients or the public, and 22% from colleagues; an area where the gap had increased.
• 58% of Disabled staff believed there were equal opportunities, but this gap had widened.
• The proportion of disabled staff who felt adequate reasonable adjustments were made had slightly decreased to 80%.

The trust’s annual WRES and WDES report was presented to the board in September 2025, acknowledging that the trust had made progress in representation and reporting but continued to face significant challenges in recruitment, progression, and workplace experience for staff from minority ethnic groups and disabled staff.

The trust had ten-point plans in place to address the issues. For race equality, the trust was adopting the NHS race and health observatory’s seven anti-racism principles, using the UNESCO anti-racism toolkit, developing a visible race equality statement, and ensuring all policies were anti-racist. Efforts were also being made to improve reporting and support for staff experiencing racism, to launch a talent management framework to address progression gaps, collect better data on training access and exit interviews, and hold dedicated WRES meetings to monitor progress.
In terms of disability equality, the trust was auditing and embedding anti-ableist practices using national frameworks, developing a disability equality statement and anti-ableist policies, and improving reporting and support for staff experiencing ableism. Additional measures included reviewing and enhancing reasonable adjustment processes, working towards Level 3 Disability Confident accreditation, running campaigns to raise awareness and promote respect, and monitoring and reporting on capability processes through dedicated WDES meetings.

Staff networks had been built to promote equality, diversity and inclusion. The trust had 4 staff networks. Each staff network had an executive sponsor. These were

• cultural diversity staff network
• disabled staff network
• LGBT+ staff network
• armed forces and veterans staff network

We spoke with staff network representatives.

The veteran’s network, had grown rapidly with about 100 members, including veterans, reservists, cadets, and family members. The network was well-supported by leadership, had strong community links, and had influenced trust policy, such as flexible working for reservists. Members felt the trust was a good place to work, with leaders actively promoting the network’s activities.

Feedback from the disabled staff network was mixed. Experiences for disabled staff varied significantly depending on team and manager, with some reporting compassion and support, while others faced challenges, particularly around reasonable adjustments. The network fostered understanding of disabilities and had developed toolkits but recognised that implementation of adjustments remained inconsistent. Executive support was described as strong, but admin support was lacking to ensure the network could fulfil all of its key roles and achieve its aims.

The LGBTQ+ network was impacted by national changes, causing anxiety among staff, especially those who are transgender or non-binary. The trust was preparing to respond proactively, but there were concerns about the visibility and responsiveness of senior leaders to these issues. The network was involved in national initiatives and collaborates with other NHS providers.

The cultural diversity network reported increased anxiety among staff due to immigration laws and societal events, with some staff limiting their movements and expressing concerns about residency and career progression. There was a perception that allegations against staff from minority ethnic groups were handled differently, and a lack of representation in senior roles was noted. However, the executive team was described as responsive and supportive, particularly in crisis situations.

Across all networks, there was an appreciation for executive engagement, but concerns remained about the consistency of support at other levels, the effectiveness of the freedom to speak up process, and the need for greater intersectionality and team working. Networks valued opportunities to influence policy and culture, but highlighted ongoing barriers such as financial constraints, lack of admin support, and the need for more compassionate leadership and improved progression opportunities.

The trust employed a highly experienced equality, diversity, and inclusion (EDI) lead. The EDI lead described how the networks had added a significant strength to the trust’s focus describing a trust historically focused on compliance with equality legislation to one which sought to foster positive change. They described networks as playing a crucial role in shaping policy, sense-checking progress, and ensuring that initiatives were coproduced, for example via the development of a reasonable adjustments toolkit, the creation of a wellness attendance policy that prioritises wellbeing and a trauma-informed approach.

The trust had made measurable progress in representation of staff from minority ethnic groups, increasing from 7% in 2015 to 13% in 2025, and had seen some staff progress into leadership roles through coaching and inclusive mentoring. The trust’s EDI action plan was mapped to national and local objectives, and regularly reviewed by a dedicated steering group, ensuring accountability and continuous improvement.

The pharmacy departments workforce strategy was comprehensive and supported ongoing staff development and leadership. Staff within the pharmacy department were supported with monthly 1 to 1s which were described as supportive and wellbeing focussed meetings. Flexible working arrangements were described in the pharmacy workforce strategy and secondments, shadowing and training and development were also integral to the workforce plan. Several staff were currently undertaking advanced leadership qualifications and royal pharmaceutical society credentialling.

The trust had clear responsibilities, roles, systems of accountability and governance structures. Our findings from other key questions and inspections of assessment service groups evidenced that these governance and assurance systems were not always operating effectively across the trust. Governance systems in place did not always ensure high quality service delivery and some early warning signs of deteriorating quality had been missed. The trust’s internal operational audit plan would benefit from clearer alignment to its risk profile. There were ongoing issues with safeguarding processes which meant that the trust did not always work effectively with partners to safeguard people and safeguarding audits were not entirely effective to manage and mitigate risks. There was ongoing work to do in relation to the reduction of restrictive practice.

The trust’s governance framework operated across three levels: the board of directors led strategic direction and assurance through committees; the executive management group oversaw trust-wide operational governance and strategic objectives, supported by various forums and care group and clinical business unit meetings managed day-to-day safety, quality, and efficiency, with regular reviews and learning groups to ensure compliance and continuous improvement.

The trust was placed in segment 4 of the NHS Oversight Framework ratings for non-acute trusts in September 2025. This meant it was identified as facing performance challenges and was likely to receive additional support from NHS England. The reasons for this were related to:

• The percentage change in number of under 18s supported through NHS funded mental health with at least one contact in a rolling 12-month period
• The percentage of adult discharges with a length of stay above 60 days
• The trust’s sickness absence rate
• The NHS Staff Survey engagement score
• Higher Reference Costs

The trust were aware of some issues with governance processes and structures and were taking action to make improvements. In 2023/2024, the trust had made several organisational changes, which included:

• changes to the executive team structure and responsibilities,
• the appointment of a new chair and non-executive directors.
• implementation of a new strategy

To assess the success of these changes the trust had commissioned an independent audit provider to review board and committee effectiveness. The trust had progressed several recommendations from these reviews; bringing in for example a new non-executive director with legal experience to chair the mental health legislation committee and adding a digital committee to the board structure to enhance oversight.

The trust had also developed a performance management framework which was in line with the NHS oversight framework, and which had been developed with stakeholder engagement. The framework aimed to consolidate existing mechanisms, such as care group well-led reviews and board assurance reporting, into a single, formal structure with clearly defined roles and responsibilities for staff, teams, executives, and committees. Performance reporting and escalation processes were standardised, with metrics and key performance indicators directly linked to the trust’s strategic ambitions and national NHS requirements. The framework promoted a culture of continuous improvement and accountability, ensuring that deteriorating performance is identified early and addressed through clear action plans.

The trust’s board assurance framework (BAF) was structured in line with national NHS guidance. Risks were clearly described, scored for likelihood and impact, and assigned to strategic objectives. Controls, mitigations, assurance mechanisms, and gaps were documented for each risk.

Across the sub committees of the board, the BAF was consistently embedded into trust governance processes. It was discussed at every committee meeting and formal BAF & risk register reviews occurred at least quarterly in all committees. Assurance levels were recorded in minutes, and triangulation across committees was noted.
Further refinement of board and committee governance processes would support the trust to meet its strategic aims and strengthen oversight of risks and deterioration in services.

The most recent independent audit(s) April 2025 into risk management and board assurance confirmed substantial assurance. Board committee papers were difficult to digest; the September 2025 people committee papers were 267 pages long while the April 2025 quality and performance committee papers contained more than 30 individual reports for review. The volume of material made it difficult for members to read, digest, and critically review all relevant information ahead of meetings, potentially undermining scrutiny and decision-making. Important issues or risks may be obscured by the quantity of content, leading to missed opportunities for challenge or assurance. Best practice recommends concise, well-structured papers with clear executive summaries and focused recommendations to support effective assurance, challenge, and strategic leadership.

Each committee chair provided a quarterly report to the trust’s public board and assurance reports to the private board. These assurance reports lacked clarity on actions required to reduce risk or make improvements.
In September 2025, the quality and performance committee reviewed reports on key areas like ligature assessments, staffing, and discharge processes. While most items received full assurance, several—such as ligature risk, community waiting times, and staffing in Cumbria—were only partially assured due to ongoing risks. Actions for these areas often lacked clear ownership, timescales, or concrete improvement plans, with some issues simply added to risk registers rather than actively addressed. Committee discussions focused on compliance rather than patient experience, and escalation to the board was routine, not always highlighting significant risks. Overall, there was limited challenge or debate, and committees did not consistently demonstrate ownership or pursue solutions for identified risks.

The trust demonstrated effective governance of the Mental Health Act and Mental Capacity Act, with strong oversight to ensure people’s rights and safety. The mental health legislation committee, supported by a dedicated team, prioritised compliance, regular audits, and continuous improvement, though challenges remained with data accuracy and the rollout of the Patient and Carer Race Equality Framework (PCREF). The team was proactive in addressing documentation, training, and SOAD referral delays, and maintained robust links with local authorities. Recent audits received good assurance ratings, and the board showed strong awareness of key risks and a commitment to ongoing improvement.

Committees’ discussions and findings were mapped directly to the board assurance framework (BAF) and relevant risk registers, ensuring oversight of key concerns such as regulatory compliance, workforce sustainability, patient safety culture, and information governance.

While the board was well-informed, there appeared to be a gap between their knowledge of risks and the depth of scrutiny regarding how these risks impact patient safety service quality. Non-executive directors sometimes offered limited challenge, which suggested an opportunity for more robust debate and assurance.

We attended a council of governors meeting and held a focus group with trust governors. The governor’s meeting was well-organised, with hybrid attendance (20 online, 18 in-person). Governors engaged actively, asking questions about committee structures, digital priorities, risk management, and regulatory breaches. There was constructive challenge, particularly around the purpose of new committees, regulatory risks, and service changes. Governors sought clarification on key risks (e.g., ligature points, learning disability training, MH legislation compliance) and requested further information or agenda items. The meeting covered a wide range of topics, including quality and performance, people and workforce, finance, audit, and annual planning. Governors were encouraged to visit new facilities and participate in service improvement activities. We noted there was limited amount of time for questions at the end of the meeting. In the focus group governors described the trust’s culture as open, transparent, and increasingly responsive, with people feeling able to raise concerns and leadership demonstrating a willingness to listen and act. The onboarding process for new governors was praised for its clarity and support. Governors felt empowered to question non-executive directors, challenge board decisions, and engage with executives. Service visits were valued as opportunities to see frontline care and influence improvements. Governors reported that views of members and the public were sought and increasingly reflected in board discussions. Senior leadership had responded to feedback, though some felt there was room to further amplify diverse voices, especially from service users and minority ethnic groups. Governors saw themselves as guardians of patient and public interests, passionate about protecting and improving services. They highlighted their role in promoting lived experience, and challenging decisions to ensure the best outcomes. Some governors noted the need for continued improvement in how staff concerns were raised and addressed, and in ensuring all voices were heard, including those of minority groups and staff governors.

The trust had a process for gathering, analysing and escalating performance data in an accessible format to the board consistently and regularly. The trust’s integrated performance report was aligned to its five strategic priorities. Statistical process control charts were used to highlight concerning, expected and improving variations. The report focussed on a range of 33 outcome measures each linked to the trust’s strategic objectives to commitments to patients, people metrics, quality care, person led care and sustainability. The report was reviewed in committees and at executive management group. An executive summary was provided outlining areas for improvement and those which had improved or met target. Recovery plans had been provided for discussion for each of these key areas for improvement.

It was positive that the trust had included oversight of prone and mechanical restraint to the
integrated performance plan in order to achieve their ambition of zero use of these methods this year. This was following concerns being raised about it’s use. The trust had continued to work towards reducing restrictive practices, particularly the use of physical interventions, however there remained work to do.

Between July 2024 and July 2025, the trust had recorded 9,944 incidents of restraint, this included 286 episodes of prone restraint and 61 episodes of mechanical restraint. Prone restraint is a type of physical restraint where a person is held face down (chest down) on a surface, regardless of whether they placed themselves in that position or were moved there. It includes situations where the person’s face is down or turned to the side. Mechanical restraint is a form of restrictive intervention that involves the use of a device such as handcuffs to prevent, restrict, or subdue movement of a person’s body or part of the body, primarily for the purpose of behavioural control There had been 204 uses of seclusion and 6 uses of long term segregation.

Analysis of restraint incidents across all service types revealed significant variation between services. In learning disability services, Mitford Unit recorded the highest overall number of restraint incidents (1,636), as well as the highest numbers of both prone restraints (91) and mechanical restraints (10). In child and adolescent mental health services, Redburn had the highest total number of restraints (1,002), while Riding ward reported the highest number of prone restraints (91). In acute adult mental health and psychiatric intensive care units, Shoredrift had the most restraint incidents (287), with Beckfield PICU having the highest amount of prone restraints (12). In wards for older people with mental health problems, Woodhorn reported the highest total number of restraints (527). The highest use of restrictive interventions both overall and for specific types such as prone and mechanical restraint was concentrated in learning disability services and child and adolescent mental health services.

During our service level inspections, we raised concerns with the trust about their use of restraint and restrictive practice. We took enforcement action against the trust in 2024 when we found that they had undertaken high levels of mechanical and prone restraint with patients using learning disability and autism services. We also found that the trust were using high levels of prone restraint and some mechanical restraint in child and adolescent mental health wards. The trust had made positive progress on this and had produced an ambition for zero prone and mechanical restraint across all trust services (unless mechanical restraint is ministry of justice approved). Whilst this was positive it was of concern that this was highlighted externally rather than via the trust’s own governance processes. We also told the trust that we were concerned about their decision to deviate from best practice with the continued use of mechanical restraint.

The trust’s annual positive and safe (use of force) report was finalised in May 2025. CNTW’s approach to restrictive practice aligned with the national restraint reduction network standards and the mental health units (use of force) Act, focusing on systemic change, robust risk assessment, and trauma-informed care. The report outlined key strategies which included cultural change, honest and transparent reporting of data, biopsychosocial formulation to improve risk assessment and expansion of meaningful activities. The report showed some improvements and the trust were aware there was more to do.

• prone restraint had reduced by 64.5% (from 1,050 to 373 incidents).
• mechanical restraint reduced by 49.4% (from 160 to 81 incidents), and by over 80% compared
  to three years ago.
• seclusion reduced by 22.3% (from 1,021 to 793 incidents).

It was difficult to understand why these areas had been chosen for focus in the executive summary of the performance report rather than highlighting all areas with cause for concern. For example, there remained several clinical priority staff training courses which were not meeting trust target. These included areas important to the provision of safe care including; adult immediate life support (69%), autism core capabilities (57%) and learning disability tier one (46%).

The trust used a structured, tiered risk management system, with risks identified, assessed (using a 5x5 matrix), and escalated from ward to board via electronic risk registers. Risks above certain thresholds were moved to higher-level registers, with the most serious added to the corporate risk register. As of August 2025, there were 13 corporate risks, mainly from community care, including; waiting times, staffing, and environmental risks. Despite substantial assurance from an external audit, some long-standing risks (e.g., CCTV, waiting lists, cyber security) remained unresolved, and some actions were overdue, particularly in inpatient care.

It was difficult to track across the trust’s governance systems how key risks to patient safety were included on the corporate risk register. These included but were not limited to:

• high use of restraint and restrictive practice
• ligature risk assessment quality and ligature incidents
• mandatory training, supervision and appraisal
• out of area placements. Between August 2024 and August 2025, the trust had 110 out of area placements. Thirty-three of these were deemed appropriate and 77 were deemed inappropriate. Numbers had decreased overall from 2023 but there had been fluctuations from late 2024.
• high levels of bed occupancy. Several acute adult wards consistently showed occupancy rates above 100% (Alnmouth, Embleton, Fellside, Longview, Lowry, Shoredrift, Springrise, Warkworth). Several forensic wards (Berwick, Linhope, Tweed, Tyne) reported occupancy at or near 100%. Rehabilitation wards also frequently exceed 100% occupancy. Most older people’s wards operated close to or above 100% occupancy, with occasional dips below this level. The Royal College of Psychiatrists and NHS guidance recommend a maximum occupancy of 85% for mental health inpatient beds to ensure safety, flexibility, and quality of care. Occupancy rates above this threshold are associated with increased risks.
• lengths of stay. Many wards, especially forensic and rehabilitation wards had average lengths of stay far above national averages. The longest reported stay was 6,199 days (Tweed). Acute ward admissions generally ranged from 30 to 90 days, rehabilitation and forensic wards often exceeded 300 days, with some outliers over 1,000 days.
• patients clinically ready for discharge. The trust reported 420 patients who were clinically ready for discharge who were delayed. The majority of delayed discharges were from wards for older people with mental health problems and Beckfield psychiatric intensive care unit.

We could see the trust were acting on these matters with clear improvement plans, workstreams and incident management groups but there lacked a central place to measure, assess and mitigate these risks.

Medicines optimisation was embedded within the trust. The medicines optimisation committee was supported by a varied staff group which ensured that medicines priorities were scrutinised and communicated at every level.

The trust had an internal audit plan. The internal audit plan was developed each year through a risk-based approach, aligning with the trust’s strategic objectives and key risks, and was approved by the audit committee.
The 25-26 operational audit plan included; risk management and the assurance framework, emergency preparedness and resilience, performance management and quality assurance. It also included; data security, system security, finance and payroll, rostering, job plans, clinical record keeping, patient document tracking, patient involvement, section 136 (place of safety), learning from patient safety, MCA, waiting list management, staff safety, board assurance framework. This was broadly aligned with some of the trust’s major operational risks, especially in areas of risk management, safety, compliance, and workforce. However, there are some gaps particularly around estates and environmental risks, safeguarding, workforce EDI, waiting times in high-risk pathways, and service transformation. Addressing these gaps would strengthen assurance and ensure the audit plan is fully responsive to the Trust’s current risk profile.

The trust understands their duty to collaborate and work in partnership, so their services work seamlessly for people. They share information and learning with partners and collaborate for improvement. Whilst good complaints processes were in place outcomes were not always clear and transparent.

The trust had a process to respond to complaints from people using services and had received 1,099 complaints in the reporting period, with 255 managed informally and 845 as formal complaints. Seven cases were referred to the Parliamentary and Health Service Ombudsman. The complaints process aligned with NHS regulations and best practice, ensuring service users, carers and stakeholders have access to a clear and fair process.

Each complaint was triaged as either standard or complex, with defined investigation timescales of 18 or 38 working days respectively, and all complaints were acknowledged within 3 working days. The trust paid attention to issues of consent and capacity, especially for third-party complaints, and had a clear escalation process for persistent or unreasonable complaints.

Learning from complaints was embedded with action plans developed and monitored to ensure improvements were made and embedded in practice.

Performance data showed that almost all complaints were acknowledged within 3 days, and the trust’s average monthly compliance with response times was 94%.

We reviewed 10 complaints. Both formal and informal complaints were investigated thoroughly, with timely communication and, where appropriate, apologies or explanations provided. In some cases, complaints were resolved quickly and locally, while others required more detailed investigation and escalation.
One area we identified for improvement was the need for complaint responses to explicitly state whether each issue has been “upheld” or “not upheld.” This clarity is important for transparency; it helps complainants understand the outcome and is recommended by national guidance.

The trust demonstrated a wide range of partnership working, both internally (across care groups, staff networks, and governance structures) and externally (with ICBs, local authorities, third sector, academic partners, and service users/carers).

The trust was committed to building trusted, long-term partnerships that worked collaboratively to improve the health and wellbeing of people and communities. As a key part of the north east and north cumbria integrated care system, the trust recognised that achieving its ambitions required working closely with a wide range of partners. The regional plan, “better health and wellbeing for all,” set out a shared vision for high-quality, equitable health and social care, with a focus on reducing inequalities, improving life expectancy, and giving children the best start in life.

The trust’s strategy was rooted in community engagement and partnership, aiming to provide evidence-based care for people with complex needs while ensuring support was accessible close to home.
Stakeholder feedback told us that they recognised CNTW’s commitment to a shared vision and collaborative working. Local authorities and partners highlighted that meeting the needs of people and communities was at the forefront of joint work, with regular joint scoping sessions and shared priorities (e.g., Section 117 Aftercare, mental health outreach, and autism strategy development).

Community and voluntary sector partners described CNTW as aware that they cannot meet needs alone, valuing the expertise of community partners and integrating them into service delivery.

Feedback from NHS partners noted strong working relationships, regular interface meetings, and joint quality forums that enabled shared learning, risk management, and collaborative planning for
complex cases.

Voluntary sector partners described partnership working as “exemplary,” citing innovative joint projects like Hope Haven and integrated crisis support services. CNTW’s willingness to invest in and reconfigure services to support system-wide solutions is highlighted as forward-thinking.

Local authorities valued CNTW’s openness to co-production, adaptability, and recognition of local priorities. There was praise for the trust’s willingness to work with third sector and voluntary partners, and for engaging in multi-agency governance structures.

Stakeholders also noted that CNTW is receptive to ideas for joint service development and improvement, and that information sharing is valued and effective.

Some partners noted that there had been occasions where CNTW could have engaged stakeholders earlier in the process of service changes, to better manage risk and operational impact. There were also suggestions to further improve escalation and communication processes between organisations, particularly in crisis situations.

Stakeholders appreciated the trust’s focus on continuous learning and innovation, including sharing training opportunities and developing integrated approaches to care. Joint forums and pilot projects were seen as valuable for system-wide improvement.

We saw examples of specific projects which highlighted good practice in partnership working which included but were not limited too; the Hope Haven project, the model of care programme board, provision of support to veterans, work with acute partners on urgent and crisis care pathways, and with local authorities on discharge planning and the development of community-based alternatives to admission.

The trust focussed on continuous learning, innovation and improvement across the organisation and the local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research. There was variable evidence of a learning and safety culture. The Trust had embedded a governance framework for patient safety and incident management but there were inconsistencies in its application which meant that learning from incidents was not consistently applied in line with national and trust policy.

The trust had developed a mature and collaborative approach to research, innovation, and quality improvement, led by a director of research, innovation and clinical effectiveness and a deputy medical director for research. The trust’s research leadership was closely linked with both clinical and academic partners.

Oversight of research and innovation was provided by the research and innovation strategy committee, ensuring that strategic direction was maintained and that new opportunities were identified and developed. A key focus for the trust was the use of evidence to influence clinical practice. The trust had re-established its learning and improvement webinars, which have become a valuable platform for sharing key messages with staff on topics ranging from risk assessment and suicide prevention to learning from high-profile cases and national reports.
The trust was the host for the applied research collaboration for the north east and north cumbria, a programme focused on applying research to improve population health, with a particular emphasis on inequalities and prevention. The trust was actively engaged in a range of regional and national partnerships, including the Newcastle health research partnership, the regional research delivery network, the Newcastle biomedical research centre, and the commercial research delivery centre. These collaborations enabled the trust to develop, deliver, and implement research that made a difference. The recently established suicide and self-harm research collaboration, led by the trust, was an example of how the trust was supporting decision-makers with evidence to improve processes, systems, and treatment in areas of greatest need.

The trust prioritised the development of research careers, particularly for nurses, midwives, and allied health professionals. CNTW worked closely with the National Institute for Health and Care research academy, and staff had secured fellowships and awards that supported their research activity and career progression. The trust led a regional consortium for a health and care professional internship programme, building on its successful non-medical research internship programme, which has supported around 60 professionals over the past 6 years.
Research was compliant with clinical trials regulations, supported by a quality management system.

The trust was one of the few mental health organisations in England to sponsor clinical trials of investigational medicinal products, with oversight provided by the research governance oversight committee reporting to the quality committee.

There was a strategic partnership between the trust and university, which enabled the trust to influence research priorities and ensure mental health was represented in regional and national initiatives. The medical director had a background in mood disorder research and led the care pathway enhancement clinic (CAPE), which was at the forefront of translating research into clinical practice. The CAPE clinic is a national exemplar, focusing on unmet needs in primary care, particularly for patients with treatment-resistant depression who are often missed by secondary care services. The clinic worked closely with GPs and community teams to identify suitable participants, and its approach was being rolled out across 15 sites in the UK.

The trust’s research delivery network funded around 20 staff, and there was a strong emphasis on engaging clinicians and staff from across the organisation.

Leaders acknowledged the challenges of sustainability, particularly for innovative clinics like CAPE, and the difficulty of bridging gaps between primary and secondary care. There was a recognised need to make research more accessible and relevant to frontline staff, and to provide quicker, locally generated evidence to support decision-making and the evaluation of new models of care. The trust was committed to embedding research more fully into clinical practice, with ongoing work in areas such as Lewy body dementia and autism and was keen to support the academic development of its workforce.

The trust had developed a broad portfolio of accredited services across its inpatient, community, and specialist mental health provision. As of September 2025, the trust had over 30 services and teams that had achieved formal accreditation status from a range of nationally recognised professional bodies. These accreditations were awarded following rigorous external review processes, peer assessments, and ongoing compliance with best practice standards. The majority of accreditations were provided by the Royal College of Psychiatrists’ quality networks, which set benchmarks for excellence in mental health care. Accredited services spanned a wide range of clinical areas, including memory protection clinics, perinatal mental health teams, eating disorder wards, rehabilitation and long-stay wards, crisis resolution and home treatment teams, psychiatric liaison services, forensic inpatient units, and electroconvulsive therapy suites.

The trust innovation group worked in partnership with NHS England, leading on quality improvement training, coaching, and large-scale change management. The team supported both trust-wide strategies and individual service improvements, offering training and coaching to staff and promoting co-production with service users and carers.

The trust used a structured quality improvement (QI) record system to capture, monitor, and communicate the progress and impact of its quality improvement projects. This system provided a clear framework for teams to define the problem they are addressing, set measurable goals, track data, and summarise the benefits and learning from their work.

The trust had developed what is believed to be the only university-accredited course for training people with lived experience in co-production in research, in partnership with the university. A recent programme development grant will support the further development of the lived experience academy, co-led by a person with lived experience, ensuring that service users are at the heart of research and innovation.

The service user and carer reference group was regularly involved in discussions and projects that shaped the future of services. During the meeting we observed, groups discussed how the service user reference group could contribute to the redesign of learning disability and autism services, digital transformation, and the patient and carer race equality framework. There was also a focus on how families could be more involved in seeking second opinions and on workforce wellbeing. Service users from Northgate secure services shared their involvement in developing an animation to support involvement work, and their ongoing efforts to improve food quality at Northgate through taster sessions and direct feedback to catering. The group also reviewed the trust’s service user strategy in collaboration with peers from another trust.

The reference group was also linked to the involvement hub, where members were invited to participate in a range of activities, such as delivering training and sitting on interview panels. Members described this involvement as meaningful and not tokenistic, with one individual sharing their experience of being on a psychiatrist interview panel.

The trust would benefit from ensuring board and committees had improved access to patient voice. The trust had paused the use of ‘patient stories’ at board as they found these had become tokenistic and were seeking new ways to improve hearing from users of their services.

Internal incident reporting was well established, with 76,000 incidents reported in 2024/25. All reported incidents underwent initial review by managers to confirm actions taken and determine if further escalation was required. Subject matter experts provided additional oversight for specific categories such as safeguarding, medicines, infection prevention, tissue viability, and security. Moderate and severe harm incidents, as well as all deaths, were reviewed by the clinical risk team to assess duty of candour compliance and determine the appropriate level of review.

From 1 August 2024 to 31 July 2025, there were 37,562 events recorded by staff at the trust in learning from patient safety incidents system (LFPSE). The majority (50%) were in adult mental health, followed by child and adolescent psychiatry (16%), learning and disability (9%), older peoples services (9%), and forensic services (4%). No harm was recorded for most incidents (67%), 167 were fatal, 107 resulted in severe physical harm, and 135 resulted in severe psychological harm. No never events were reported.

We were not assured that staff always correctly categorised incidents within this system, this reduces the opportunity for escalation and learning. We completed a key word analysis for incidents involving incidents of aggression and restrictive practice because this had been a focus during our service inspections. From the total 37,562 events recorded by staff at the trust LFPSE, there were 26,606 that included one or more of these search words or terms. 15,353 (58%) of these incidents reported neither physical harm nor psychological harm as result, although the level of concern for 656 of these was reported as ‘very concerned’. This suggested some mismatch between level of harm and level of concern.

The trust had not made enough improvement in this area, and it impacted on early identification of signs of deteriorating quality in services. When we conducted an inspection of wards for people with a learning disability and / or autism in 2024, we told the trust that we were concerned about the way in which staff recorded and reported incidents and how they reported them to safeguarding. In the year prior to that inspection, 491 injuries were reported for 29 service users across Mitford Unit, Mitford Bungalows, and Rose Lodge, with most incidents classified as low or minor harm and nearly half involving self-harm. Safeguarding referrals were much lower than the number of incidents, and there was no clear record of how many injuries resulted from restraint or other causes. There had been similar concerns raised about the reporting of incidents at the child and adolescent mental health units in 2025.

The trust had guidance in place which was mainly aligned with NHS England’s patient safety framework guidance and guidance on harm grading. The trust’s “Incident Policy Incorporating the Patient Safety Incident Response Framework (PSIRF) Practice Guidance Note Incident Reporting and Immediate Management – V08” gives detailed examples of levels of harm which should be recorded for certain incident types. These examples illustrated how harm levels escalate with the severity, duration, and consequences of treatment required. For example when an incident involves a service user potentially overdosing with medication in the community, the trust policy describes low harm categorisation as involving short‑term A&E treatment with antidote and discharge, moderate harm requires inpatient admission and several days of monitoring, and severe harm involves life‑saving intervention, ambulance attendance, and prolonged hospital care.

A detailed review of incidents reported as ‘no harm’ by trust staff in the LFPSE system revealed several cases that, according to the trust’s policy, should be reclassified due to the nature and severity of the events. There were multiple overdose incidents, some requiring ambulance intervention. Ligature attempts were also reported, and significant self-harm was documented along with physical assaults and aggression with possible injury. These examples demonstrated that the original ‘no harm’ categorisation did not always accurately reflect the actual risk and impact of these incidents and was not always in line with trust policy.

The policy deviated from national guidance because the categories for psychological harm had not been included in the policy. These deviations could lead to under-reporting of harm severity, particularly in cases involving psychological impact. The trust confirmed that psychological harm is included in their web based incident reporting system but was not currently outlined in the policy. The trust are reviewing the policy with a view to supporting staff and making the required policy changes by the end of June 2026.

Learning was reinforced through structured processes, although during our assessment of services it was not always clear how learning was disseminated to front line services and changes made because of incidents. It was also unclear how learning from external reviews such as CQC inspections was shared across all services. For example, we raised a concern with the trust about the quality of ligature risk assessment following the death of a patient in June 2023. At our assessment of wards for older people with mental health problems in 2025 we found similar concerns about the quality of ligature risk assessments and how the trust had not applied refreshed national guidance. We were concerned that the trust was not taking learning from serious incidents and using national guidance to improve the quality and safety of care.

The patient safety learning and improvement panel was a well-established forum that oversaw key areas such as falls, medicines, addictions, complaints, and workforce issues. Using the NHS patient safety and learning framework, the trust set quality aims for 2024–2025 focused on fostering a positive and safe culture, improving physical healthcare, reducing self-harm, and enhancing care for people with severe mental illness. Priorities included consistent risk assessment, safer transitions, early recognition of deterioration, and supporting staff wellbeing. The panel’s thematic reviews have led to tangible safety improvements, such as introducing Life Vac devices to address choking risks and relaunching the physical health strategy in response to identified gaps.

The trust had a process for reviewing incidents in line with the NHS patient safety and learning framework. The trust conducted early learning reviews (ELRs) within three days of patient safety incidents, followed by after action reviews (AARs) or patient safety incident investigations (PSIIs) for more serious cases. In the past year, they completed 172 ELRs, 124 AARs, 17 PSIIs, 50 mortality reviews, and 145 responses to HM Coroner. We asked the trust to provide data on whether the timescales outlined in their policies were met, but they were unable to provide this information.
Action plans from reviews were tracked and approved by senior leaders, with thematic reviews informing quality priorities. In 2025, 457 learning points were identified, mainly around care processes and risk management.

The trust responded to two prevention of future death reports and participated in three independent reviews, which highlighted ongoing weaknesses in risk management, care planning, safeguarding, and communication.
We reviewed a selection of ELRs, AARs and PSIIs. The cases included incidents involving medication errors, self-harm, complex care transitions, and being absent without leave from services. Reports provided detailed chronologies, multi-perspective analysis, and open reflection on both clinical and system-level issues. Most reviews included clear, specific, and actionable recommendations, with a focus on learning rather than blame. Reviews demonstrated sensitivity to the impact on patients, families, and staff, and documented the support offered. Immediate action was taken to manage incidents which presented ongoing risks.

Some ELRs identified risks (such as medication and waiting list issues) but the reports did not evidence concrete improvement actions, representing missed opportunities for learning. Not all reviews fully explored or documented system-level issues, particularly in cases involving inter-agency working (e.g., with acute trusts or police). Some reports were lengthy, making it difficult to quickly extract key learning points. The inclusion of executive summaries and clearer action plans would enhance practice and drive improvement.

Between July 2024 and July 2025, the trust had received 2 prevention of future death reports (Regulation 28) from HM Coroner. Regulation 28 of the Coroners (investigations) Regulations 2013 relates to “Prevention of Future Deaths” (PFD) reports. After an inquest, if a coroner believes that action should be taken to prevent future deaths, they have a statutory duty to issue a Regulation 28 report. This report is sent to any person, organisation, or authority that the coroner believes has the power to take such action. The trust had responded to both reports clearly articulating the actions taken in response to the concerns raised in both cases with clear actions undertaken to reduce reoccurrence.

Leaders were aware of the trust’s impact on environmental sustainability. They were able to provide examples of where the trust had made changes to reduce the trust’s carbon footprint.

The trust had a clear strategic ambition to become a sustainable, high-performing organisation. The updated green plan (2025–2028) set out a comprehensive framework for environmental sustainability, including a detailed estates decarbonisation strategy. This encompassed capital planning, heat decarbonisation, and renewable energy initiatives.

Governance arrangements were well established. The green plan management group, chaired by the director of estates, oversaw delivery across nine thematic workstreams: transport, buildings, medicines, food, waste, digital, workforce, supply chain, and care models.

The trust had embedded sustainability into its digital infrastructure, adopting a cloud-first strategy, extending device lifecycles.

The trust had taken a pragmatic and inclusive approach to workforce engagement. Staff were actively involved through sub-workspaces and delivery groups, with strengthened leadership engagement across estates and clinical teams.

The trust had made demonstrable progress in optimising its estate to support sustainability goals. Key achievements included:

• completion of the Cedar project, delivered with green assurance
• strategic land repurposing
• development of shared care hubs and utilisation of void space

Fleet management was advanced, with 90% of vehicles now electric or hybrid, supported by tracking software and tax incentives. Catering services had been aligned with low-carbon objectives, including food waste reduction, water removal technologies, and sustainable procurement practices.

Carbon emissions had reduced by 1,699 tCO2e (14%) over five years. However, current levels remained above the required trajectory, and the trust acknowledged the need for accelerated reductions. Supply chain emissions were now tracked using carbon factors per £ spent, reflecting a more sophisticated approach to indirect emissions.
The trust had secured over £6M in sustainability-linked funding, including public sector decarbonisation scheme grants, with a 12% internal match. Capital projects included:

• de-steaming and decentralisation of heating systems
• thermal upgrades at Bamburgh site
• solar panel installations and biodiversity initiatives

Challenges remained, particularly around conservation area constraints, legacy infrastructure, and project timing. The trust remained on track to achieve a 47% carbon reduction by 2032, in line with its net zero roadmap.