Sandwell and West Birmingham Hospitals NHS Trust

On this page

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

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

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

The trust had a shared purpose, vision, and values. This was based on equity, diversity and inclusion, and improving lives and health outcomes for people. It was drawn up to meet local and national priorities, through engagement with staff, patients and key stakeholders, and understanding the challenges and needs of the population and communities. The trust culture was based on inclusion, equality and organisational values. Although there was more to do, and some areas had seen improvements, most staff were supported, and their wellbeing and a just culture was carefully considered. However, improvements were needed to ensure actions taken were reviewed to determine if they had made a difference, and these actions were in line with what was of most concern for staff. There were also several concerns from the staff in the pharmacy service about wellbeing and their job roles. Staff in other services we met were also concerned about culture and many feeling morale was poor in some areas and staff feeling undervalued. Some staff from different roles across the trust were concerned there was a focus on money above all other factors.

Our findings:

The trust had a comprehensive strategy for the 5 years from 2023 to 2027, so it was at the mid-point of delivering against its strategic plan which included opening the Midland Metropolitan University Hospital (MMUH). The strategy was based around 3 key objectives of:

• Our Patients – to be good or outstanding in everything we do

• Our People – to cultivate and sustain happy productive staff

• Our Population – to work seamlessly with our partners to improve care and lives.

The trust’s narrative in the strategy report recognised the fundamentals of care were key for patients to receive safe care, a good experience, and the best possible outcomes. Within the three objectives above were strategic objectives and measures of success. There were also objectives linked to the five-year strategic objectives for the current financial year (or ‘in-year priorities’). There were measures of success built into the strategy. These included localised measures such as what patients were saying in national surveys. There were measures including seeing a reduction in patient harm, reduced mortality, and improving access to services for patients against national standards. These were linked to wider-ranging measures in being able to demonstrate the trust was contributing to an increase in improved population health, increasing local employment at the trust (employment being known to improve health); and achieving financial stability.

Each in-year objective was underpinned by agreed measures. Each measure was led by members of the executive team which fitted with their substantive role and identified trust specialty leads. For example, the chief medical officer led on ‘improve recognition and management of deteriorating patients’. The acting chief financial officer led on ‘deliver recurrent financial improvement’ and the group chief people officer led on ‘reduction in temporary staff’.

Of the six in-year objectives, the trust board were provided with evidence against the pre-determined measures of success. The trust was either on track to achieve the measure or was off track but with a credible plan and delivery still being assessed as achievable. The only area which was partially off track with no viable plan was part of the objective around working with partners to improve population health The risks and mitigations around this were not clearly stated and were incomplete.

For transparency, the strategic measures of success against the 5-year strategy were presented to the board and available on the trust website. Of the 33 key activities listed as measures, 20 were on track and 10 were off track but with a credible plan to be delivered. The final 3 were listed as ‘status undefined’. This was within the activity of ‘increasing local employment’. However, the trust had reported positive steps in that the latest data for June 2025 reported almost 60% of staff lived within 5 miles of the trust site where they worked. This had improved from around 54% in the previous June.

For consistency in approach, each paper presented to the board was required to indicate which part of the trust strategy it aligned with – our patients; our people (staff); or our population. The board structure for the bi-monthly public meeting was divided (after the standing items) into sections on the same 3 strategic objectives. For example, learning from death, the maternity update, and the winter plan assurance statements were linked to ‘our patients’. Workforce reports and the equality, diversity and inclusion update were linked to ‘our people’.

The place, neighbourhood and population health report was linked to ‘our population’. This report linked to the strategic objective of working with partners to improve population health. We report more on this in our section of ‘partnerships and communities’ below. Otherwise, the board were updated on in-depth work with the Sandwell Health and Care Partnership where there was progress on integrated intermediate care and urgent neighbourhood services which were measured as ‘excelling’.

It was noted there was more to do around population health management. In work with the West Birmingham Locality Partnership, the plan was based around key factors within the locality which included a younger diverse population with some of the poorest outcomes for early childhood development, infant mortality and low uptake of immunisation and vaccines for children. Suicide and drug and alcohol use were reported as particularly high. Strategic priorities around improving population health were therefore linked to these known factors with mental health prevention priorities being one area of focus.

The strategy was updated in 2025 to extend the vision from “to be the most integrated care organisation in the NHS” to include … “and to be part of the most integrated care system in the NHS.” The strategy was updated to include a continuous improvement system with learning and development as part of culture.

Other trust strategies referred to the trust’s values and the key themes and how the objectives linked to each of them. The trust’s values were co-produced with stakeholders and launched in 2022 accompanied by a behavioural framework. The values ran through many of the trust’s policies, frameworks, strategies, and plans. This included, for example, values-based recruitment, the values-based leadership programme, and values-based staff annual reviews (appraisals).

Each strategy was produced in a similar template to ensure they linked to the overarching trust strategy. For example, the people strategy used the same language and format around objectives and milestones for consistency and to demonstrate it was joined up. As with the overarching trust strategy, the priorities were divided between the time before opening the new MMUH hospital and the time afterwards. The trust strategy recognised the dedication and commitment needed from staff to open a brand-new hospital and that some aspects of trust life would need to be paused. However, there was commitment from the people strategy to new developments focused on staff. One of these was the opening of a new learning campus in 2027 with a focus on providing programmes for school leavers for further education through to degree-level apprenticeships, work placements and employability schemes. The people strategy was linked closely with the trust’s values of Ambition, Respect and Compassion. The staff experience programme known as “with you all the way” was designed to embed the trust’s values and included the introduction of the ARC leadership and team effectiveness programmes (see further around culture below).

The trust’s medicines optimisation strategy (published in 2024) aligned with the overall trust’s plans. The pharmacy strategy was launched just before moving to the new MMUH site and was updated shortly after the move. A one-year review looked at the pharmacy strategic objectives which involved putting people, patients and population at the centre of the review. The vision was to be a “valued and recognised clinical service in our own right.” However, although pharmacy staff agreed there was a sense of common goals there was also a feeling of isolation and being unsure of what the shared vision and strategy were, including their role in developing and achieving it. This was particularly evident from staff not based at MMUH who told us they found it difficult to engage as there were no meetings and little opportunity to contribute. The senior leadership team acknowledged this and were aware of staff frustrations. They explained that now the MMUH move was a year on that everything would be refreshed in January 2026 when staff would be more involved.

Turning to culture, and the 2024 NHS Staff Survey, which was the latest available staff survey, there was some improvement in the views of staff, of whom 2,744 (34%) responded. This response rate was slightly increased over the 2023 response (2,296 – 29%) although was a poor response rate when benchmarked with the average response rate for similar organisations of 49%. However, it was noted that the timing of the staff survey coincided with the move to the new MMUH hospital which would possibly have had some impact on resources. The highest response rate of recent years was 39% in 2021 and the trust was aware there was work needed to much improve the number of staff who took part in this pivotal study of staff experience.

In March 2025, the trust board (in private session) had received an early, fair, and detailed report on the 2024 staff survey, and this had included a considered list of actions identified to drive improvement and improve staff experience. However, although this report was produced only shortly after the results had been provided to the trust, none of the actions described how to strengthen the response rate. The NHS had identified how the strongest performing organisations (as measured by the NHS Single Oversight Framework) had the highest levels of staff engagement which included responding to the NHS staff survey. However, the October report to the people committee picked up on the response rate as well as highlighting for the committee some of the changes to the 2025 survey. It noted the response rate for the 2025 survey (which was open from 6 October to 28 November 2025) was already improved at the midpoint over previous year because of a “strong…engagement campaign.” The committee was also provided with indicative response rates by division and directorate to know where to focus efforts.

The 2024 staff survey had some strong positive indicators for the organisation. In the 9 key leading indicators, six of the responses were considered as ‘significantly higher’ than those of the previous year. Four of the 9 measures were slightly better than the national average and none were significantly worse. However, in the three leading indicators in the ‘compassionate culture’ area, each were worse than the national average, although each had improved since the previous year. Balancing this, in terms of motivation, 68% of staff reported they were enthusiastic about their job. This was up 4% since 2022 and the same as the peer group average for 2024.

The trust recognised a just and learning culture created a safe environment where people could raise issues and demonstrate accountability when things went wrong. Leaders recognised a just culture meant staff were receptive to learning and improvement. Staff we met said they felt the trust encouraged a restorative rather than retributive culture. Those staff we met at Sandwell Health Campus talked about how the NHS Patient Safety Incident Response Framework (PSIRF), which had been rolled out at the trust, gave opportunities as intended for learning from incidents and avoided apportioning blame or responsibility for errors. Alongside this, the trust had introduced a new ‘conduct at work’ policy with support from colleagues from the trades unions. Training had been rolled out for supporting staff who were undertaking formal investigations and supporting the early resolution of people management issues.

There was a recognition of the value of an inclusive and fair culture for people who worked within pharmacy. However, this was being impacted by concerns about the workforce staffing levels. The Chief Pharmacist had been resourceful in ensuring there was the right skill mix to deliver a safe and effective pharmacy service. For example, when the pharmacy department was asked to reduce their workforce by 17 staff the Chief Pharmacist negotiated based on securing patient safety and reduced the number to 3 non-clinical and 1 clinical member of staff so the delivery of services to patients was not directly impacted.

Although there was delegation and accountability across the pharmacy workforce this was said to be due to the professional responsibility and goodwill of the team covering for roles not being replaced due to a lack of funding. For example, the Chief Pharmacist had been the interim Medicine Safety Officer for a year which had not been replaced due to funding. This role is required to be separate from the chief pharmacist role due to the amount of work involved: Patient Safety Alert – Improving medication error incident reporting and learning 20 March 2014. When we raised this with the senior executive team, the Chief Executive Officer wrote to us just after our inspection visit to advise the Deputy Chief Pharmacist would adopt this role, which was being formalised.

Due to a lack of funding, pharmacy staff were concerned there was no opportunity for job promotions which increased the number of staff leaving, affecting progression and retention. The wellbeing of the workforce was important to the team. However, due to the vacancies and the impact this had on reduced learning time, some staff expressed a feeling of being overwhelmed. Staff at MMUH, and not just pharmacy staff, but senior clinicians as well, felt the lack of any dedicated space for learning, quiet time, or confidential discussions had an impact on their wellbeing.

There was commitment from the staff-side trades union representatives to have a useful and meaningful role in the organisation. The relationship with these staff had improved after noted tensions in recent years. The three representative staff we met had good insight into many issues in the organisation and worked hard with colleagues in the trust to raise their issues through the right channels. They gave us valuable feedback about certain issues affecting staff, not least those in the lower job grades. One area was staff in lower grade roles having no access to a computer to, for example, read trust emails and see their pay slips. They were concerned a large cohort of staff had no NHS email and missed out on correspondence as a result. We fed this back to the trust leadership team who responded by arranging to place additional IT equipment in shared staff areas for. However, this was at MMUH, and staff at Sandwell Health Campus raised the same issue with us, although this was after our initial feedback to the trust leaders.

There was a range of communication opportunities for staff across the organisation and the public. The objective for the communications and engagement team was to support the organisation’s strategic objectives by making sure communication with everyone was clear, accessible and accurate. The trust used ‘awareness days’ to educate the public and staff about key health messages. These included days or weeks focusing on sepsis (for World Sepsis Day); public awareness of ‘looking after your heart’ (for World Heart Day); and reaching the public about blood pressure, with monitoring guidance and recommendations on how to respond.

There was a positive sense of change and enthusiasm from many staff we met. During this assessment work, we visited each of the 3 main hospitals and held open invitation focus groups with staff. Almost all the staff we met at the focus groups felt the culture of the organisation was mostly good and they were well supported. Many of them had worked for the organisation and its predecessors for many years and felt a clear sense of community and collaboration.

Staff at Sandwell Health Campus said they felt well supported and their local leaders were visible and approachable. They said they felt valued and there was good teamwork. Other parts of the organisation such as healthcare science staff felt they were getting a ‘voice’ these days. Staff said they would recommend their site as a place to work and there were great opportunities to develop. The vertical integration of primary care with acute services had been of real value to staff and patients alike. Staff said they were proud of the trust’s work in community integration particularly around areas like frailty and maternity.

Areas of concern from staff at Sandwell Health Campus were around communication and opportunities for wellbeing. Staff said those who did not have regular access to a computer felt they were missing out on electronic communication from the intranet and emails. They also mentioned how staff who worked in clinics could not book wellbeing sessions as these were usually offered with 2 weeks’ notice, and clinics they needed to run were booked 6 weeks in advance. They also spoke about the problem with electronic records and data and systems not talking to each other. They said the rollout of new systems was sometimes too rapid to bring everyone on board.

Staff at City Health Campus felt there were good development opportunities when you had the right leader or manager. Those staff who had benefitted from education and training opportunities talked about how they wanted to ensure their own teams had the time and encouragement to also benefit from the trust’s education packages. However, several staff spoke about appreciating the breadth and depth of the courses, but how the reality for them was too often having insufficient time to attend anything they had booked. They also spoke about having to withdraw from courses or their own team members having to withdraw often with almost no notice to be able to cover staffing shortages. This was a key theme for all those we spoke with. They recognised the benefit of this training in meeting other colleagues and building a network but were anxious at how often they could not attend.

Almost all the staff we met at City Health Campus said their primary concern was with staffing levels. There was some concern from staff about the amount of forms required to be able to fill a shift with a member of bank staff and how this could lead to shifts not being filled. We were told multiple clinics were being cancelled each week because of staff shortages often from unplanned sick leave. Staff spoke of how they were having to repeat requests for bank staff every week to cover maternity leave and how this administration took them away from other priority work.

Other concerns were around having time and the facilities to hold staff meetings, with so many staff working a myriad of different hours and shifts. It was sometimes hard to complete continuous professional development when accessing a computer was problematic. Some staff did say they felt isolated at the City Health Campus from the rest of the organisation. They were concerned about the level of road traffic making travelling hard and the safety of the staff at night when much of the site was closed. However, when we asked what the key motivation was for them coming to work, they all said it was being there for the patients and the inclusivity of the hospital staff.

Staff at Midland Metropolitan Hospital again talked about there being shortages of staff as a major concern and the negative effect on morale. They also spoke about how this and other pressures meant they were unable to do much else than clinical work or their administrative tasks and not get to training or development opportunities. Others talked about the challenge of bringing two hospitals together and opening a new hospital. Most said it had been a great success but exceptionally hard work for all involved. Most recognised the opportunities this gave and how lots of teams were now working far more closely together.

However, staff also talked about being verbally abused by patients and the public due to staff shortages and growing waiting times for patients. Staff said they often finished work late and the pressures of so many new staff needing mentoring and induction was constant. Some staff were having to work from home to complete administrative tasks. We were also told how many staff said they were tired and exhausted, and sickness was increasing as a result. They spoke about the focus being on saving money to the detriment of other aspects of their roles. However, staff were positive around teamwork and living the organisation’s values.

There were three subjects that came up more often at MMUH than others across different staffing groups which we were told led to some poor morale. These were the working environment and specifically the lack of office space at MMUH which meant some clinical staff were unable to sit down and work at any time during their shift. Some said they were standing all day and using computers on stands or crouching over laptops. There was a lack of locker space for staff, and some had their property stolen.

Another was the issue with achieving safe levels of staff due to what was described by staff as financial constraints. This was specific for the nursing and medical staff. Allied Health Professional staff (such as imaging and physiotherapy) reported this as less of an issue. The third was around systems and digital progress. Many staff said there were problems with patient record systems not talking to each other; concerns about the sustainability of the digital team with staff unsure about their futures; and the pace of change being hard to manage effectively. This was specifically in relation to virtual wards and between the patient’s GP and the hospital consultants as they used two different electronic systems. This caused issues with access to view patients medicine records. Although workaround processes were introduced it increased the risk of a medicine error. It was on the pharmacy risk register and pharmacy were looking at governance procedures regarding medicine safety issues. This would include looking at other centres that have successfully implemented a virtual ward set up to reduce any unnecessary steps and risk.

Our report below on governance, management and sustainability highlights more concerns with the digital strategy and progress which would be likely to fail to meet its objectives without some significant investment.

There had been an improvement in several important and key questions around culture within the staff survey over several years. However, all those below were below (worse than) the peer group average. These included:

• Q25a: The care of patients is my organisation’s top priority – At 72% this was on an improving trajectory in the last 3 years from 2022. The peer group average in 2024 was 74%.

• Q25b: My organisation acts on concerns raised by patients – At 67% this was at the highest level in the 3 years from 2022. The peer group average in 2024 was 71%.

• Q25c: I would recommend my organisation as a place to work – At 59% this was the highest level in the 4 years from 2021. The peer group average in 2024 was 61%.

• Q25d: If a friend or relative needed treatment I would be happy with the standard of care provided by this organisation – At 59% this was the highest level in the 4 years since 2021. The peer group average in 2024 was 62%.

• Q6a: I feel that my role makes a difference to patients – At 87% this was the highest level in the 3 years since 2022 and was just below the peer group average in 2024 of 88%.

In the measure of a group of questions around culture, the trust scored 6.91/10 for having a compassionate culture. This had improved each year since the measure began in 2021, although below the peer group average of 7.05/10. In areas around culture 2 indicators were noted positive outliers in the improving trend. These were:

• Q8b: 67% of staff said the people they worked with were understanding and kind to one another. This was up from 2023 (64%). It was close to the peer group average for 2024 of 69%.

• Q8c: 68% of staff said the people they worked with were polite and treated each other with respect. This was up from 2023 (66%). It was also close to the peer group average for 2024 of 70%.

The following 2 key indicators of staff morale had improved in 2024 and were close to the national average:

• Q26a: 28% of staff said they often thought about leaving the organisation. This had dropped from the peak in 2022 of 33% and was much the same as the average of the peer group for 2024.

• Q26b: 22% said they would look for another job in the next 12 months. This had dropped from the peak in 2021 of 26% and was close to the average of the peer group for 2024 of 21%.

In positive responses (in terms of an improving picture) around health and wellbeing, staff who responded to the NHS Staff Survey from 2024 said:

• Q11c: 41% had felt unwell in the last year due to stress. Nevertheless, this was the lowest result (best) for the last 5 years since 2020. The peer group average for 2024 was also 41%, but nevertheless a statistically significant number.

• Q11d: 56% of staff said they had come to work in the last 3 months despite not feeling well enough to perform their duties. This was the lowest result (best) in the last 4 years since 2021. The peer group average for 2024 was also 56%. Also, a statistically significant number.

• Q12e: 38% of staff felt worn out at the end of their shift. This was the lowest result (best) in the last 4 years since 2021. This was better than the peer group average for 2024 was 42.5%.

One question which was not improving was in relation to Q11a: my organisation takes positive action on health and wellbeing. This had fallen 7% from the peak in 2021 to 52% in 2024 which was 4% worse than average and in decline in each of the four years since this metric was measured.

The trust had responded to what had been consistently poor feedback from staff and being in the bottom quartile of NHS trusts (in the comparable group). In March 2024, the trust implemented a new engagement approach. This was to enable local leaders to work with their teams to identify changes that mattered most to staff in their immediate areas of work. A ‘people engagement team (PET)’ was established to improve and increase staff engagement and co-produce local action plans. There were then established local PETs for each division focusing on local issues and needs. There was no overarching action plan for the trust board to track, as each division had its own action developed alongside the people engagement team for the division. As part of the drive to encourage staff to complete the 2025 NHS Staff Survey, there were a series of posters produced to demonstrate the actions taken by the PET to improve working life for staff. This included (but by no means limited to):

• Making regular 1:1 meetings mandatory in the medicine and emergency care division

• Making appraisals more meaningful for staff in primary care and community teams

• Launching monthly peer-led ‘knowledge bites’ sessions available in the surgery division

• Improving cross-site collaboration and regular meetings in the imaging team (as confirmed by staff we met)

• Improving knowledge and awareness of how to conduct personal development reviews in the women and child health division

• For all staff, the trust launched a series of awards, including relaunching the long-service awards, and hosting celebration events. Since July, the trust had made 1,165 awards to colleagues.

The trust carried out ‘pulse surveys’ every three months to get a more up-to-date view of staff views. However, this was responded to by only around a quarter of trust staff. The results were analysed and reported through the trust’s people committee. Although there was a good level of detail in the report, it was not easy to determine whether the actions being taken aligned with the areas where staff were most concerned. There were also no questions asked about the area which concerned staff we met the most. This was being unable to step away or being pulled back to their key role and unable to participate in learning due to staff shortages. This was not borne out in the latest NHS Staff Survey 2024 although the question around enough staff was improving and at the highest level for the five years of the data comparison. In 2024, 36.2% of staff, against a national average of 32.8% said there were enough staff to do their job properly. This had increased from a low point in 2022 of just 24.4%. However, it remained only just over a third of staff in 2024 who said there were enough staff.

To further respond to the staff survey, the trust launched a programme focused on culture, l learning, values and leadership called: “with you all the way.” Towards the end of 2025, the trust re-set the “with you all the way” culture group to bring several groups working on people (staff), engagement, and learning together. The progress of equality, diversity and inclusion, staff experience, engagement, wellbeing, and values programmes would be measured through this more cohesive approach.

The trust had been one of NHS England’s first wave of organisations to embed the ‘Flex for the Future’ scheme around flexible working for staff. This involved the introduction of new flexible working, home working and retirement policies. Also, promotion of flexible working and support to managers to consider applications. This was to enable staff to have a better work-life balance and retain a more diverse workforce. The 2024 NHS Staff Survey supported this and showed:

• Q6b: My organisation is committed to helping me balance my work and home life – 48% of staff agreed, which was up from 43% in 2021 and up each year to 2024.

• Q6c: I achieve a good balance between my work life and home life – 54% of staff agreed, which was up from 49% in 2021 in a continued increase.

• Q6d: I can approach my immediate manager to talk openly about flexible working – 70% of staff agreed, which was up from 61% in 2021 and increasing each year.

The combination of these metrics produced a ‘sub-score’ of 6.25/10 which was better than the national average of 6.17/10.

The trust had implemented the NHS Sexual Safety Charter which was launched by NHS England towards the end of November 2023 after reports of the prevalence of sexual misconduct in the healthcare sector. The trust had implemented 10 actions to protect staff and patients from unwarranted sexual misconduct. This included:

• A process for onward referrals to the Horizon Centre (sexual assault referral centre)

• A bespoke ‘first disclosure’ training programme with 40 staff having completed the training so far. These staff had been provided with the skills to support colleagues reporting sexual assault and/or harassment.

• A sexual safety review group to assess all reported concerns to determine what should be learned and improved for staff safety

• Independent sexual violence advisors to support patients or staff who were victims of sexual assault.

A dedicated page had been made available on the trust’s website after we advised the trust we were struggling to find information about the charter.

There was an effective process with a compassionate approach to protect doctors in training, resident doctors, and locally employed doctors. The trust had appointed a consultant as the guardian of safe working hours (GSWH) with the current appointee to the role having been in the role for around two years. This role was introduced by NHS England alongside the new ‘junior doctors’ contract’ in 2016/17. The GSWH must be (and was) independent of trust management and a champion for safe working hours for doctors in training and oversee safety-related exception reporting. Exception reporting included doctors working longer hours than scheduled, not able to take rest breaks, limited educational opportunities (due to workload) and absence of senior support when needed.

The GSWH reported to the trust board, although this had only happened once so far this year, in May 2025. The trust informed us this was now to be an agenda item every quarter as required along with the production of a consolidated annual report. A statement was included in the trust’s quality account for 2024/25 and included information, as required, on rota gaps and plans for improvement (recruitment) although it did not refer directly to the work of the Guardian.

In the report presented to the board, exception reports made by junior doctors were listed but although we recognise the numbers were comparatively low, the report was low on detail. The report only recorded the number of exception reports in each year since 2022, but with no analysis of the reasons or any identified trends which needed to be addressed. This information would have provided the board with actions it needed to take to tackle the reasons for doctors reporting their concerns. The GSWH report was required to produce information for the board on rota gaps for all shifts, although this was not provided or analysed. The was no detail on the closure of exception reporting and how any exception payments had been used.

Nevertheless, other than reporting gaps not recognised by the board and limited detail, the Guardian had an excellent commitment to the role. They were focused on ensuring all exception reports were made in accordance with expectations, and they were addressed by the specialities or leaders as required. There had been action taken to reduce the number of doctors who were staying beyond their shift concerned they had not handed over their patients. The guardian had led sessions on ‘handover etiquette’ and gone further to ensure resident doctors had good access to senior clinicians and organised department teaching every Thursday. This had been extended to include managers and administrators to find solutions to concerns when needed. There were social evenings organised with other clinical staff for team building. Alongside this, medical staff were given specific roles such as leading in rota preparation, mandatory training, and the staff survey.

Another role of the GSWH was, alongside the medical education team and wellbeing leads, to facilitate resident doctors’ forums to bring doctors in training together to discuss their experiences. These were taking place each month. There was also the ongoing offer to speak with the GSWH at any time. This could be on a one-to-one basis or with a group or team as needed. The Guardian also noted they were not always the first port of call for issues, which was evidence of a strong supportive culture among the resident doctors and consultants, which we heard about in other conversations (see culture). The GSWH was also part of the national guardians’ group for shared learning and knowledge.

The trust had a wellbeing support service focused on 7 elements of good health and wellbeing. In terms of personal health and wellbeing, the trust had an employee assist service with a free and confidential helpline 24 hours a day. It provided help and counselling around issues such as stress, anxiety, bereavement, financial wellbeing, drug and alcohol issues, and mental health problems, among many others.

The trust provided an occupational health service for staff for both physical (such as musculoskeletal disorders and joint pain), mental health problems, and specialist clinics. The service provided, for example, free physiotherapy (with typically only a 1-week wait), immunisation, and menopause support. There was a wellbeing hub at the Sandwell Health Campus open Tuesday to Thursday 8am to 4pm for confidential conversations, relaxation, and sessions for teams to book together.

Professional and pastoral wellbeing support was available for staff. This included support for medical staff with consultants providing specific support to resident doctors, and others for their senior colleagues. This work included delivering education around wellbeing; teaching sessions around caring for yourself; wellbeing check-ins; and bespoke sessions. We met with the wellbeing leads who were passionate and insightful. They described having made significant progress in the transformation of the support mechanisms and focusing on wellbeing but were enthusiastic to do more. They recognised the difficulties staff faced after the Covid-19 pandemic and areas where the organisation needed to learn from gaps in pastoral care.

There were some compassionate support programmes for doctors, recognising the risks and anxieties often accompanying the jobs they do. Two consultants led programmes with one focusing on their peers and the other on resident doctors and doctors in training. Programmes included a 2.5-day residential wellbeing course for consultants looking at a range of issues including burnout, handling difficult relationship with colleagues, nutrition, and sleep. There had been excellent feedback from attendees of whom 25% said they may have taken sick leave if not for the programme. There were weekly meetings with the resident doctors, and a programme of work designed around three main areas:

• Ordinary human needs (such as rest spaces, nutrition and hydration, and sleep education)

• Culture of connection including a programme of bespoke induction

• Caring for the carers – recognising the support for doctors caring for patients including processing clinical experiences.

A medical education programme the ‘Thriving in Medicine’ training scheme was available for resident and doctors in training to provided key foundations for sustaining a career in healthcare.

There were services for nurses and midwives from professional nurse and midwifery advocates. Staff were able to be part of a variety of networks, including for those with disabilities and long-term conditions; the clinical women’s network; women’s staff network; and staff representing those from minority groups. There was also a multifaith chaplaincy team for people of faith and none. The trust had Sikh, Christian, Hindu, Muslim and Catholic chaplains and could contact representatives of other faiths on request. City Health Campus, Sandwell Health Campus, Rowley Regis Community Hospital, and MMUH had chapels/multifaith worship halls and most had Wudu (washing facilities) and hosted Friday prayers.

The trust had a range of facilities for staff and promoted the idea of rest breaks and rest spaces. The wellbeing brochure designed for staff described the spaces and facilities available which included the MMUH art gallery, on-site spiritual centres, the courtyard gardens at Sandwell, the gardens at Rowley and the spaces on level 5 of the MMUH (a non-clinical floor). The trust awarded staff for their hard work and dedication at an annual award ceremony with around 50 individuals and teams recognised.

The trust had leaders at all levels who understood the context in which they delivered care, treatment and supported and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. However, some staff did not feel their concerns were listened to, particularly around safe staffing levels and temporary cover, and some quite senior staff still felt unable to speak up at a more local level. Some staff felt their values and morale were challenged every day due to work pressures. Not all senior staff felt they were able to influence change.

Our findings:

There were inclusive leaders at all levels who understood the context in which care, treatment and support were delivered. Our interviews with them showed they embodied the culture and values of their workforce and organisation. The leaders were knowledgeable about the issues and priorities for the quality and safety of services being provided within a complex and pressing financial situation. Leaders were alert to most examples of poor culture where it affected the quality of care and/or had a detrimental impact on staff. However, due to the not uncommon and legal complexities of HR policies, not all poor behaviours were addressed quickly, and some investigations were taking time and affecting morale for some staff.

We met with senior leaders and found a committed, hard-working, and dedicated group of people who were focused on their staff, their community and their patients. We also met the nursing, allied health professional, and medical leadership teams. There was mutual respect and support among all the staff we met. Each recognised how their services were different but were committed to working together, being consistent and taking decisions to support better patient care. We noted exceptional commitment from the consultant leaders to supporting and developing their resident doctor colleagues, with a dedicated wellbeing lead. The senior nurses and allied health professionals we met were kind, committed and honest. There was noted mutual respect, and they spoke about the visibility and support from the chief nursing officer, and how her values resonated throughout the nursing leadership.

The medical leadership were committed, supportive and engaged. The trust had a chief registrar supporting resident doctors. Doctors leaders felt there were good opportunities for open and honest conversations with the chief medical officer, who was described as always approachable and visible. It was recognised that staff based in the community and other trust hospitals beyond the MMUH could feel isolated at times and efforts had been made to be as inclusive as possible. A senior doctor we met at a focus group commented on the strong level of support and commitment across the senior leadership teams. Resident doctors we met said they genuinely felt listened to and supported. We were told the trust had a good reputation among medical school graduates as a preferred location for training.

Leaders were generally visible and approachable to most staff. However, some staff we met said they had rarely seen any of the executive leadership team. They recognised though this was not always easy in such a large organisation. Some also said the new MMUH design meant people were generally less visible to one another. Staff we met at focus groups at the other hospital sites said they found their premises more “sociable”, and they saw senior staff perhaps more easily than staff working at MMUH.

Many of the executive team were described by their staff as providing a good balance between autonomy and support. There was a strong group of divisional leadership teams (usually with a divisional lead consultant, lead nurse and operational manager). The teams had developed and nurtured a valued process of cross-divisional working for the benefit of more joined-up patient pathways and care and shared learning and development. This included the community teams which encompassed the GP practices the trust managed as well as the range of community nursing and therapies.

In the pharmacy team, staff told us the chief pharmacist, and the senior leadership team were all approachable and visible even though the staff group were widely spread across three sites. The senior leadership team explained how they tried to remain visible to staff and rotate between the three locations although they felt the ability to do this had slipped over the last year due to the MMUH move. Staff had regular 1 to 1 meetings with their line manager which they said were a good opportunity to discuss any issues and they felt listened to by management. Talent within the pharmacy department was encouraged with a pharmacy sponsor in the participation and engagement team. This involved national pharmacy days and focus groups with staff.

There were promising improvements in staff metrics in the NHS 2024 Staff Survey around leadership and management. High numbers of staff who reported (although this was only a 34% response rate from of all staff) thought their leaders were compassionate about patient care and staff wellbeing. In the 2024 survey 6.96/10 staff who responded said they felt there was compassionate leadership. This was up from 6.80 in the previous year and up each year since the measure was started in 2021 but was just below the NHS peer group average for 2024 of 6.98.

In more direct management questions in the 2024 survey, staff reported on their managers’ support in these responses (all of which had improved over 2023) and most were typical of the national picture:

• Q9g: 71% said their immediate manager was interested in listening to them when they described the challenges they faced. This was a 2% improvement over the previous year and the same as the peer group average for 2024 of 71%.

• Q9h: 69% said their immediate manager cared about their concerns. This was a 2% improvement over the previous year but slightly below the peer group average for 2024 of 70%.

• Q9i: 67% said their immediate manager took effective action to help them with any problems they faced. This was a 3% improvement over the previous year and the same as the peer group average for 2024 of 67%.

Most staff we met felt confident they could speak up, and their voice would be heard and how this had improved from a time when this was not always the case. The Freedom to Speak Up Guardian service had grown and developed and was mostly respected and run by committed and caring individuals. Evidence from the NHS Staff Survey 2024 had showed improvements in most areas relating to staff confidence about speaking up and issues being addressed. However, there were areas around reporting that needed to be strengthened specifically around examining why a disproportionate number of staff had reported detriment or demeaning treatment from speaking up. The trust also had not given an entirely fair reflection of its self-assessment of the requirements of the Freedom to Speak Up Guardian service. Some staff, including senior staff, told us they still did not feel confident to speak up and did not really understand what the service was for.

Our findings:

The trust had established a Freedom to Speak Up Guardian service as required around 10 years ago following Sir Robert Francis’s report into failings at the Mid-Staffordshire NHS trust. The relatively new team provided confidential advice and support to staff where they were concerned about direct or indirect risks to patient safety or the ability to deliver quality care.

The Freedom to Speak Up service was reorganised and reconfigured in 2023 with a new Guardian appointed and a group of around 25 champions reestablished to support colleagues across all sites. Most staff we met knew who the Guardian was and where they could access information about contacting them or one of the champions. Most also knew the executive sponsor on the trust board. Several staff told us they felt the service was trusted across the organisation although said this had not always been the case in the past. Some staff felt their more junior colleagues still felt unable to speak up, and some we met felt not all staff understood the remit of the Freedom to Speak Up service. There remained several staff who said they did not feel they would suffer detriment from speaking up, but that nothing would be done to resolve their concerns.

In comparison with other NHS trusts of a similar size, Sandwell and West Birmingham sat in around the middle in terms of how many contacts were made by staff. We do not take large numbers of contacts to indicate a poor culture, as this could mean staff are willing and feel confident to speak to a guardian on any subject. Equally we do not take small numbers as indication of a failing service by the guardian, or all is well in the trust. We have found some trusts with small numbers to have staff who are confident in raising matters with their direct managers in the first instance and this often leads to resolution.

In terms of this trust, with a service considered by many staff as ineffective a couple of years ago, the number of cases rose each 3-month period from April to June 2023 (Q1 2023/24) to a peak in July to September 2024 (Q2 2024/25) before tailing off in the third and fourth quarters. However, in data not yet reported to the trust board, but from the National Guardian’s Office, in the 3 months of April to June 2025, there had been a significant rise in cases from 27 in the previous quarter to 97 – the highest since the trust started submitting data in 2022/23. This was the second highest number in the Midlands region. However, in previous quarters, the number of cases appeared to be relatively normal and not showing signals either way of a poor speak-up culture. This was borne out by the results of the latest NHS Staff Survey (see below).

The peak time of July to September 2024 aligns with concerns raised with CQC about an unhealthy work-life balance and issues with the effectiveness of the Freedom to Speak Up service. However, after the move to MMUH was completed, there were fewer concerns raised with us and with the Guardian, suggesting pressures on staff had eased. This was the experience described by some staff we met.

The NHS 2024 Staff Survey results showed improvements for the annual staff survey around freedom to speak up with the trust being mostly the same as the national average:

• Q25e: 60% of staff said they felt safe to speak up about anything that concerned them, and this had improved each year since 2020. The peer group average for 2024 was also 60%.

• Q25f: 48% of staff said they felt confident the organisation would address these concerns. This had also improved each year since 2021. The peer group average for 2024 was also 48%.

• Q20a: 71% of staff (peer average 70%) felt secure in raising concerns about unsafe clinical practice. This was more staff than the previous year, but below the peak of 74% in 2021.

• Q20b: 56% of staff felt confident the organisation would address these concerns (peer average 56%). This was the highest level since 2020 (57%).

In the year 2024/25 (presented to the board in May 2025), the types of concerns being heard were (note in the 184 concerns, some may have more than one element):

• Worker safety or wellbeing (86%)

• Inappropriate attitudes or behaviours (67%)

• Bullying or harassment (28%)

• Patient safety concerns (16%)

• Detriment (9%)

The area concerning staff reporting detriment (disadvantageous and/or demeaning treatment because of speaking up) at 9% (17 cases in the year) was higher than the overall value for similar trusts in the Midlands (1.6%). It was also nearly 3 times higher than the next trust which reported 6 cases. A member of staff we met said they felt they had suffered detrimental behaviour from speaking up and had been “shut down” by executive staff, despite it taking a lot of courage to speak up. However, this issue around detriment was not picked up in the board report, and no action was noted as required to consider how to address this issue. The report also did not cover actions taken in the previous year to manage any perceived areas of weakness, so no assurance was provided on progress or plans for future action.

Although it was not picked up specifically in the trust board paper, there had been a large spike in the number of people who were reporting concerns but wishing to remain anonymous. This was in the period July to September 2024 where there was a peak of cases reported. The number reported anonymously was 35% when previous concerns and those in following months had rarely been raised anonymously. This was also an issue for the latest published data from April to July 2025 where 15 of the 97 concerns (15%) had been raised anonymously. There was no mention of this rise in cases or rise in anonymous concerns in any board papers or committee papers in those we reviewed from July to November 2025.

The trust had completed its self-reflection and planning tool as required by the National Guardian’s Office on how it assessed its Freedom to Speak Up service. There were mostly well-thought-out actions recorded in the tool to address areas of improvement needed. However, these had not found their way into board papers within, say, the annual or six-monthly report of the Freedom to Speak Up service, and there was no obvious route to demonstrating where actions had been taken effectively.

Furthermore, some of the scores against certain areas could be said to be not a fair reflection. In the self-reflection, no area was scored below a 3 which suggested all areas were “applied well, or strengths, or best practice”. For example, in principle 4 and statements about training, the trust scored itself as 3 on mandating of the National Guardian’s Office and Health Education England training but then went on to state it had “not mandated the training.” In principle 5, it scored a 3 on all managers and senior leaders having received training on freedom to speak up but going on to state there was “no training yet provided.” As reported above, the trust had a high number of reports of staff facing detriment. This was not reflected in the trust’s self-assessment in principle 7, even though it scored 3 of the 4 statements as 4. A score of 3 was “generally applying this well, but aware of room for improvement or gaps in knowledge/approach.” A score of 4 was “an evidenced strength and a strength to build on.”

Diversity and inclusion were valued in the workforce. Leaders supported work towards creating an inclusive and fair culture. They acted to continually review and improve the culture of the organisation in the context of equality, diversity, and inclusion. Leaders took action to improve disparities in the experience of staff with protected equality characteristics, or those from excluded and marginalised groups. However, not all interventions were adequately monitored to evaluate their impact. There were limited or no measures of progress used to determine what was or was not working.

Our findings:

The trust had an equality, diversity and inclusion (EDI) plan (strategy) for the five/six years of 2022 to 2027 (other documents said 2023 to 2027). It was therefore around halfway through the plan. There were 4 key areas for staff which extended to the experience of patients and communities in this context, and were:

• Enabling collective leadership

• Creating a positive culture of compassion and inclusion

• Improving staff experience

• Delivering inclusive services to our patients and communities.

The actions underpinning the four key areas included launching the new leadership framework to support leaders to role-model behaviours and challenge bias and unsafe practice; ensuring people felt they were able to speak up safely and be heard; strengthen the diversity of the workforce and progress targeted plans around equality metrics; and better understand the needs of community including support for disadvantaged groups through access to training and employment.

One of the measures of success around trust staff was for improvements in the Workforce Race Equality Standard and Workforce Disability Equality Standard metrics. Another was rising numbers of staff from diverse backgrounds in more senior roles. These were good objectives for real progress. However, not unlike some other trust documents, what was missing from the plan document were measurable ways in which the trust could be assured the actions were making a difference. There was a section on measuring improvement but no aims or objectives apart from a list of data it might collect. It did not say what improvements were expected. For example, the bullet point list said: “retention and vacancies” and “levels of sickness” but it did not say anything about what it expected from data about these areas. It did not describe what the data was reporting at the point of producing the report and where it expected it to go once the actions had been completed.

The trust had actions to address staff experience around race, disability and other equality measures. As part of its broader commitment to promoting workforce diversity and inclusion, the trust tracked progress through the Workforce Race Equality Standard (WRES). The WRES data helps organisations to understand the experience of people from ethnic minority backgrounds and act to ensure they have equal access to career opportunities and received fair treatment in the workplace. The 2025 WRES data presented a mixed picture of both progress and challenges.

The equality metrics revealed both progress and ongoing challenges for the trust. The trust board were advised of results from surveys of staff in terms of their race through the WRES. However, there was insufficient evidence to show how actions taken in the past had made any impact or how any proposed actions were to be measured. The reports to the board in September 2025 were also muddled with some typographical errors around dates with some reference to 2024 when this was intended to report on 2025 data. We reviewed the report from September 2024 to identify key actions to improve 2025 results, and these were unclear. The 2024 report had detailed metrics and described proposed developments for the future but set no clear objectives for 2025. The 2025 report was also detailed on metrics but did not report how actions had led to progress and did not clearly describe a new set of measurable actions.

Nevertheless, the WRES report for 2025 highlighted some areas of positive impact from trust programmes around inclusivity and equality. This included a reduction in disciplinary action taken against staff from an ethnic minority background (the trust continued to use the term BME for non-white staff which the government asked public bodies to remove from use in 2021 – and the trust committed to us it would now make that change). There was an increase in staff from an ethnic minority background reporting equal access to promotion. We also noted an improvement in representation of staff from an ethnic minority across most NHS Agenda for Change bands, including at band 8d and band 9 as well as across medical roles, which was positive for the trust and reflected improved diversity in representation.

However, these metrics and others still showed a negative disparity with staff identifying as white. In areas which had declined or were static, fewer staff from an ethnic minority background were likely to access mandatory training and continuous professional development opportunities. More staff from ethnic minorities said they had been harassed by the public and colleagues. Discrimination at work remained unchanged but disproportionately affected staff from an ethnic minority. There had been no improvement in representation on the trust board of people from an ethnic minority.

However, the trust had acted by promoting a scheme called the Inclusive Talent Management Programme to support staff from under-represented groups to develop into senior leadership roles. The pilot programme required staff to have first completed the Black Country Integrated Care Board Next Generation of Leaders programme. They then embarked on a programme tailored to their individual needs supporting staff from an ethnic minority background to progress their career aspirations. One of the members of the pilot group presented their positive experience to the trust board in September 2025. Those who had participated said they felt ready to progress as a result and felt their confidence and experience had much improved.

The Workforce Disability Equality Standard (WDES) was a set of measures which enabled NHS organisations to compare the workplace and career experiences of disabled and non-disabled staff and ensure disabled staff received fair treatment in the workplace. The trust records showed 4.8% of staff declared a disability. In the latest NHS Staff Survey (2024), around 640 staff stated they identified as someone with a long-term condition or illness (LTC) (therefore classed as a disability) with around 2,000 who did not (note the overall response rate was from 33.9% of all staff – 14.7% below the average response rate). This representation of people declaring a disability had increased year-on-year over the past 5 years as had the number of people employed by the trust declaring a disability. However, the trust’s performance in the WDES metrics was mixed, with some indicators flagged as better and others worse than the national value, but all of them having had improved over the last 4 years.

In the NHS Staff Survey 2024, the percentage of staff with a disability who reported having experiencing harassment, abuse or bullying from patients/service users, their relatives or the public in the last 12 months had declined since the peak of 39.3% in 2021. In 2024, the percentage had dropped to 26.1% which was better than the national average of 29.4%. However, like all measures in the staff survey for people with an LTC, it was above that for the rest of staff (19.6%), but the gap had also slightly reduced. Also falling since the peak of 2021, was the percentage of staff who experienced harassment, bullying or abuse from managers in the last 12 months. In 2024 this was reported by 15.8% of staff with an LTC illness. This was worse than the national average of 15.1% and twice the average for the rest of the staff group (7.5%). Slightly more staff than average of those with an LTC (53.3%) were reporting this experience which was worse than the average (51.8%).

Improvements were reported including in the proportion of staff with an LTC feeling pressured to work while unwell. This had dropped to 27.9% of staff from 40.4% in 2021. Of those staff without an LTC, 46.7% said they felt valued in their work, but this dropped to 33.7% of those staff with an LTC.

The trust’s actions around people with a long-term condition included implementation of a health passport to “enable constructive conversations between disabled colleagues and their managers regarding health needs and reasonable adjustments (with training).” Furthermore, development of a reasonable adjustments framework; and focus groups with the network group for people with a disability.

The trust had produced the Public Sector Equality Duty (PSED) Annual Report for 2025 as required by NHS England. This was a detailed report stating how the trust had fulfilled its responsibilities under the Equality Act 2010. It reported on the key highlights around creating a more inclusive culture. The report stated progress on the equality, diversity and inclusion plan was reported to the people committee and upward to the trust board. Progress reported on included the trust achieving the Race Equality Code Accreditation in May 2024 which was valid for 3 years. The trust had taken part in phase 2 of the NHS national Rainbow Badge Scheme and achieved bronze status as part of a tiered (bronze, silver, gold) accreditation framework. This scheme was for trust staff to be able to demonstrate through policies, training, and patient engagement, they were aware of issues LGBTQ+ people might face in healthcare. Phase 2 enabled trusts to demonstrate their commitment to reducing barriers for LGBTQ+ people.

Disability work was recognised. In July 2024, the trust was recognised as a ‘Disability Confident Leader’ Level 2. Disability Confident encouraged employers to think differently about disability and take action to improve how they recruited, retained and developed disabled people. Level 2 meant the trust had been able to demonstrate evidence of an inclusive culture around recruitment and management practices.

However, as with some other trust documents, the WRES and WDES reports to the board were light on detail about the achievements and impact of previous actions plans, how they had been measured, what had worked well and what actions were not having an impact.

There was a commitment to supporting equality, diversity and inclusion through peer-to-peer networks. The trust had several staff network groups to support equality, diversity and inclusion. We met with leaders representing some of the current staff networks. Most of the thoughts of the group were around positive changes and problems being dealt with far quicker than in the past. Each network had an executive and non-executive director sponsorship which was appreciated. One of the concerns from the group, which was not unique to this trust, was staff finding time to attend group meetings or getting cover from colleagues. Some community team staff felt more excluded due to being more remote from those in the acute hospital sites.

There remained a gender pay gap at the trust although the gap was narrowing. As required by the Equality Act 2010 Regulations 2017, the trust published its retrospective gender pay gap report for 2024/25 (reported October 2025) as it had done each year since 2017. The gender pay gap related to reporting the difference between average rates of pay for men and women in an organisation. It also anticipated future mandates by providing a comparative analysis by gender, disability and ethnicity covering March 2023 to March 2025, including bank staff.

In the most recent report to the board through the people committee (October 2025 for the financial year 2024/25) the trust data showed there were 78% of staff who were female and 22% male. This ratio had changed marginally over the last few years with the number of females slightly decreasing. The smallest percentage of female staff were employed in the highest quartile (highest paid) group with the largest percentage of male staff in the same quartile (highest paid) group. This ratio had remained largely unchanged over the reporting period since 2017. It was attributed to by the trust as due to the skew towards males in the consultant workforce (34% female, 66% male).

There was an improvement in the median gender pay gap over the past 5 years. In 2024/25, the trust had a 9.5% gap between the median hourly pay for men and women. This was down (had improved) from 11.2% in the previous year. In a basic comparison with UK data, this was better than the national figure for April 2025 for all staff (part-time and full-time) of 12.8%. At this trust, women earned on average around 91p for each £1 earned by male colleagues. The median gender pay gap figure is the difference between the hourly pay of the median man and the hourly pay of the median woman. The median for each is the man or woman who is in the middle of a list of hourly pay ordered from highest to lowest paid. In 2020/21 the median gap was 17.3%, in 2021/22 it was 18%, and in 2022/23, 12%. The trust had been reporting on this downward (improving) trend in its board reports.

When comparing mean average hourly pay, women’s pay was 25.7% lower than male colleagues. The mean gender pay gap figure uses hourly pay of all employees to calculate the difference between the mean hourly pay of men, and the mean hourly pay of women. The average rates of pay were affected by the disproportionate number of staff by gender working in the lower or higher paid bands.

In terms of bonus pay (local clinical excellence awards), there was a significant difference in the payment rate between men and women and in the number of people receiving bonuses. For 2024/25, the median bonus pay gap was 22%. It was noted by the trust in its board report that this gap had increased (worsened) in both the mean and median measures, but this was due to a change in the rules around awards.

The people committee report of October 2025 on the gender pay gap stated there had been positive progress in reducing gender gaps in pay, but there was more to be done before there was a significant closing of the gap. The report described actions taken to reduce the pay gap in the previous 12 months. These included:

• Promoting policies such as flexible working, shared parental leave, and remote/hybrid working

• Holding career conversations with female staff through the women’s and clinical women’s networks

• Comparing pay gaps across the system to identify areas of good practice.

However, as with comments elsewhere in our report, there remained no measures of success described and no action plan to work towards making a material difference to this inequality. The issues from the gender pay gap did not form part of the inclusion strategy for the trust. There was no mention of what the comparison of pay gaps had found or where good practice had been seen.

There was a significant risk in the ability of the trust to manage its digital infrastructure safety and effectively. Some areas of clinical audit and particularly use of national guidance were significantly non-compliant. There was limited evidence to show how the trust was reviewing clinical outcomes for patients at board level. There were concerns around the time taken to review some serious incidents and whether a mechanism existed to determine if learning, including immediate learning, had been implemented and led to reduction in further risk of harm to other patients. Although in an improving trajectory in some key areas, there were clinical performance standards not being met and some below (worse than) local and national averages or being slow to improve.

There was more to do in some cancer waiting times, although some were much better than the national average for waiting or treatment times. Some trust reports were not providing evidence to show trends in data or links between learning and themes. Also, data was being gathered and used for challenge but needed to be more readily available in granular level for divisions and teams. The trust’s policy and practices in some areas of Disclosure and Barring Services did not meet the legal requirements.

However, the trust had clear responsibilities, roles and systems of accountability within difficult and relentless financial pressures. Leaders acted on information about risk, performance and outcomes, although needed to bring a sharper focus to learning, audit and outcomes.

Our findings:

Although with some new appointments, there was a mature and functioning trust board with good corporate memory and credible information and data. The committed and highly experienced group of non-executive directors spoke of being included and able to represent their communities and those areas in which they took governance responsibility (typically trust board committees). The trust had an established unitary board structure with public meetings held every two months (with a board workshop in between) which were well attended and planned. The board covered key headline statutory requirements and relied on its committee meetings for some of the more granular detail.

The trust evaluated the performance of its board and committees. In September 2025, the trust board reviewed the effectiveness of the board committees over 2024/25, summarising the work they focused on. Cross-cutting themes were noted, and the board concluded the committees had operated effectively and fulfilled their terms of reference. However, our concern was with the significant portfolio carried by several of the executives who had group appointments across this trust and the Dudley Group trust. This was being managed though by strong and committed deputies or divisional teams in the roles such as, but not limited to, people management, nursing leadership, and medical leadership. The medical staff we met also paid tribute to the operational managers, teams and individuals who, they felt, sometimes did not get sufficient recognition.

Headline and key performance data was mixed with some, such as urgent and emergency care data, being worse than local and national averages for the sickest patients. Other data in cancer, diagnostics, referral to treatment times, was mixed throughout with some better, some worse or unchanged for some time. At the time of our assessment, the most recent published performance data for AE was for October 2025. Ambulance handovers within 30 minutes were 78.2%, better than the target set by the integrated care board of 65%. The number of patients waiting in AE for more than 12 hours for a bed after a decision was taken to admit them was 13.6%. This was much the same as the national average of 13.4% but better than the local average of 20.7%. The trust had been below (that is better than) the local and national averages since the early spring of 2025.

In terms of the leading NHS constitutional standard for urgent and emergency care, the trust was worse than both the national and regional averages for the percentage of type 1 patients (most serious) waiting 4 hours or less in AE. This was 54% in October against the England average of 60.1%, the regional average of 57.9%, but still significantly below (worse than) the interim national standard of 78%. When adding the patients attending the urgent treatment centre (type 3) the average waiting less than 4 hours improved to 73.3%. Despite this risk being of significant concern to staff we met, the trust had deescalated this from the corporate risk register in September 2025 as it was satisfied with the measures set up to manage this in the emergency department.

The trust was making progress, albeit slow, to see more patients within the NHS constitutional standard to see 92% referred to treatment within 18 weeks. However, this had deteriorated over the last 4 years far more than the national picture. For October 2025, the trust had seen 57.7% of the total patients waiting within 18 weeks, against a national average of 61.7% and regional Midlands average of 60.7% (ranked 9th of the 12 local NHS acute trusts). In January 2022, the trust treated 66% of patients in 18 weeks, which by May 2022 had risen to 69%. This then fell to a low point in December 2023 of 54% and not returned to 2022 levels since. The ICB had set the trust a target for March 2026 of 65% which did not appear achievable.

Although the 18-week standard had only slightly improved in the last 2 years, the number of patients waiting had dropped. In October 2025, there were 64,755 patients on the trust’s waiting list, which had dropped from just over 76,000 in October 2023. In terms of long waits, in October 2025 there were no patients waiting over 78 weeks; 3 patients waiting over 65 weeks in January; and 812 patients waiting more than 52 weeks. These 52-week waits for patients represented 1.3% of the waiting list against and better than the national average of 2.3% and the Midlands region of 1.9%. The ICB had set the trust a target for the percentage of patients waiting 52 weeks of 1% by March 2026 which did appear achievable. In October 2025, services (those with large patient numbers over 1,000 waiting) performing best against the national standard for 18-week waits were:

• Respiratory medicine 91.2% (national average 66.7%)
• Ophthalmology 75.3% (national average 71%)
• Dermatology 65.3% (national average 62.9%) although with rising patient numbers

Those where performance required improvement were:

• Ear, nose and throat 37.2% (national average 51.3%)
• Neurology 40.8% (national average 57.6%)
• Cardiology 43.2% (62.7%)
• Gynaecology 45.7% (57.4%)

The trust had action plans in board papers most of which were ongoing, although the actions for gynaecology were off track for delivery. A new tele-dermatology service started in September (digital images used to provide quick advice to GPs to avoid hospital appointments where possible) and patients being graded in terms of their risk. The waiting list was expected to be halved by March 2026.

The number of patients waiting for diagnostic tests had been fluctuating although had reduced considerably over the past 2 years – although there was more to do in some areas such as MRI and CT scanning. The NHS constitutional interim standard for NHS trusts was for not more than 5% of patients to wait more than 6 weeks of a referral (the pre-Covid standard was 2%). In October 2023, 54.1% (31,097) of patients at the trust had waited more than 6 weeks. This was around twice the national average of 24.7% waiting over 6 weeks. Two years later, and by October 2025, the number of patients waiting had fallen to 23,296 with 28.4% now waiting over 6 weeks. This was closer but still worse than the 21.3% national and the regional average of 24.2%. The target set by the ICB for March 2026 was for no patients to be waiting longer than 6 weeks which appeared unlikely to be achieved.

There were still some patients waiting far longer than 6 weeks for diagnostic tests. For September 2025, 6.6% of patients had been waiting more than 13 weeks for their scan, although this was lower (better) than the national average of 7.5% and regional average of 7.7%. In the major patient groups, the most patients waiting for more than 6 weeks were for neurophysiology tests (56%) and MRI scans (39%). MRI scanning patient delays were higher than the local average (21.7%) and the national average (17.4%). MRI scanning was not listed in the September 2025 integrated performance report among the key recovery actions for diagnostics, although neurophysiology did have an action plan for improvement. However, the trust board were advised of the risks from delays in MRI and CT scanning in another paper in September 2025. This included reviews of possible harm occurring, immediate outsourcing of patients waiting over 4 weeks for an MRI scan, and consultant review of cases with longest delays.

The trust’s cancer waiting time performance largely aligned with both the regional and national averages. However, in specific disease types, some areas were a cause for concern. The 28-day Faster Diagnosis Standard (FDS) was established to ensure patients would be diagnosed or have cancer ruled out within 28 days of being referred urgently by their GP for suspected cancer. For patients who were diagnosed with cancer, it meant their treatment could begin as soon as possible. For those who were not, they can have their minds put at rest more quickly.The NHS target was for 77% of patients to be seen within 28 days. The percentage of patients in the year from 1 November 2024 to 31 October 2025 was 76%. The percentage of patients who were seen within the 28-day FDS in October 2025 was 79% - therefore better than the standard and better than the national average of 76.1%.

However, the proportion of patients seen within 28 days for both suspected head and neck cancer (39%) and suspected lower gastrointestinal cancer (61.5%) was notably below the standard. The statistics for the cancer type were, respectively, 78% and 66.6% nationally. At this trust, the patient base for those two cancers accounted for 25% of all suspected cancer patients treated. However, of the largest patient groups, the trust was exceeding the national standard. In suspected breast cancer patients, 91.4% of patients were seen within 28 days in October (87.3% nationally); suspected skin cancer, 91.9% (78.2% nationally); and suspected upper gastrointestinal cancer, 85.3% (76.9% nationally).

The 62-day pathway had too wide a range of performance from poor to excellent. The 62-day referral-to-treatment standard meant patients who had been referred for suspected cancer from any source and go on to receive a diagnosis should start treatment within 62 days of their referral. The NHS standard was 70%. The trust’s performance in this metric was very variable, although good when seen overall. The percentage of patients in the year from 1 November 2024 to 31 October 2025 seen within 62 days was 69%. In October 2025, the total for the trust for all cancers was 69.8%, but in individual specialties there were some areas of poor performance. This included gynaecological cancer at 20% and haematological (lymphoma) at 33.3%. However, breast, upper gastrointestinal, haematological (other) were close to or above 90%. The trust was ranked in the middle 50% of trusts in England.

There was more to do to meet the 31-day cancer standard. The 31-day decision-to-treat to treatment standard means patients who had a cancer diagnosis, and who have had a decision made on their first or subsequent treatment, should then start that treatment within 31 days. The NHS target was 96%. The percentage of patients in the year from 1 November 2024 to 31 October 2025 was 91%. In this period, the trust had not met the 31-day decision-to-treat to treatment standard in any month, coming closest in March 2025. The trust was ranked in the lowest quartile in England at the end of October 2025. One of the main reasons was around the poor performance in treating patients with skin cancer. There were no specific key recovery actions reported.

We were concerned, as were several of the clinical staff, that the trust did not have a senior experienced lead nurse or a team of nurses for support to patients with dementia, despite being an integrated organisation. NHS England recognised the role as pivotal for helping to lead, deliver and coordinate relationship-centred care to help improve the experience of patients, carers and staff. To also support specialised education and training for staff. It was said the role was devolved to nurses on wards, but staff told us this did not work well in practice with the patient safety lead nurse stepping in voluntarily when needed to help in this area.

The trust acted when it was advised of clinical safety alerts. For example, the trust investigated those patients who had been fitted with a trifecta heart value of a type which had been shown to have issues with degeneration before that would be expected. Those patients potentially affected had been placed on enhanced monitoring.

There were variable results for hospital-onset healthcare associated infections. In the annual report of infection prevention and control 20024/25, the trust was reported as within statistical expectations for cases of MRSA, E. coli bacteraemia, and Klebsiella. Incidences of MSSA showed a 25% increase over the previous year but there were no local or national trajectories to benchmark. However, there was a sharp increase to 85 in the number of Clostridioides difficile (C Diff) infections against the NHS England upper limit of no more than 52 cases. This compared to 55 at the trust in the previous year. This increase was also seen nationally, and the trust quality committee were advised of investigations being undertaken by NHS England and the UK Health Security Agency to determine the cause.

The comprehensive annual report presented to the quality committee in August described actions on tackling infections to be taken in the following year. However, it did not report back to the committee on the success or otherwise of actions taken in the previous year given there had not been a material improvement in the numbers of infections seen. Actions were described in the report for 2025/26 but without clear explanation of how they would be achieved in practice. For example, one action described “Ensure that IPC remains a priority…” but not how this would be orchestrated. Another was: “Continue to aim for zero cases of MRSA bacteraemia.” However, there were no measurable actions to allow the quality committee to determine if this was achievable or how it would be delivered.

The trust reported it was compliant with the Department of Health’s Hygiene Code and NHS England’s Infection Prevention and Control Board Assurance Framework. However, it recognised there were issues with some of the ageing estate and challenges presented by areas including ventilation and waste management. The trust reported how investment in the older sites, particularly Sandwell Health Campus, was needed to resolve some of these intractable issues.

The trust had produced and submitted its plan for the winter of 2025/26 and completed the board assurance framework. The plan was submitted to the board in July 2025 and included a statement confirming it had been drawn up with reference to the wider healthcare system. The chief operating officer had been identified as the lead for the winter plans. At the September board meeting, the only outstanding action listed was for a system-wide winter planning stress test which was scheduled for 17 September 2025 with any learning to be immediately implemented within the plan.

There was a recognised risk and concern due poor performance in both falls risk assessments and completion of early warning scores (NEWS2) for patients. Falls risks assessment compliance was reported to the trust’s quality committee as a fundamental of care indicator. In October 2025’s report it was recognised as an issue (September being 22.8% compliance against a target of 95%). July, at just 28.2%, was the peak over the six months from April to September 2025. Despite this, data showed there was no particular increase in patient falls, including those with harm. Actions were being taken to highlight the issue around falls risk assessments although this did not include an expected trajectory in improvement.

The completion of National Early Warning Scores was also cause for concern. This set of metrics is a process for staff to identity and escalate patient care if that patient is found to be deteriorating in some or all clinical measures used. It was noted from the trust’s quality reports that the data was not wholly reliable, but not if it might be far better or worse than indicated. However, the clear concern from results being around 68% on average across 2025 (trust target of 90%) led to the relaunch of the deteriorating patient steering group with monthly meetings established from September 2025. The board had been informed through the strategy update April to June 2025 (at the September 2025 board meeting) of the in-year objective to improve the management of the deteriorating patient was off track to be met. Two of the 3 activities, namely improving systems and communication, and resuscitation readiness and system ownership were both off track but with recovery plans identified. The third activity of strengthening clinical governance and leadership was on track although with more to be done.

The deteriorating patient metrics were being enhanced by the roll out of Martha’s Rule. This was an NHS England initiative that allows patients, families and carers to request an urgent review by a specialist clinical team if they consider a patient is deteriorating. This was being implemented at Sandwell and West Birmingham NHS Trust, although it was too early at this stage to report on comparative data.

The trust was monitoring and reporting on national mortality data. The latest mortality data was described by the Standardised Hospital Mortality Indicator (SHMI) to be ‘as expected’. SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die based on average England figures. The number considers the characteristics of the patients treated at the hospital or trust. The latest SHMI for the period May 2024 and April 2025 was reported as 103.1 which had fallen from the previous cumulative data spread from April 2024 to March 2025 of 104.3. The most recent data for April 2025 individually was 92 showing a positive downward trend. Prior to this, all SHMI data points and the cumulative number were above the risk-alert level of 100 indicating somewhat higher numbers of deaths than would be expected. The September board papers recorded how this was a higher number than acceptable and trust-wide improvement efforts were continuing.

The other measure of mortality, the Hospital Standardised Mortality Rate (HSMR) is a health indicator comparing the actual number of patient deaths to the number predicted. It is based on the patient’s age, conditions and severity of illness as predictors. A score of over 100 is a warning sign that there might be potential issues. The trust’s HSMR for the most recent month (July 2025) was 89.73 and cumulatively 102.46. This was in the expected range and had been steadily declining (improving) in the last year.

The trust acted on high mortality rates. In 2023 (published 2024) the National Hip Fracture Database reported a ‘much worse than expected’ mortality rate for patients with hip fractures. Board papers from July 2025 recorded how the trust invited the British Orthopaedic Association to conduct a review which identified areas to improve as well as good practice. The report and associated action plan would be reviewed through the quality committee of the board.

There was learning from avoidable death and where poor practice had been identified. The topic of ‘learning from death’ was covered in a report to both the quality and safety committee each month, and a full annual report to the trust board. The annual report referred to and met the requirements of the National Quality Board guidance on learning from death (2017). With the introduction of the role of medical examiner, the trust was involving and supporting patients’ families following death of a loved one. The medical examiners for both acute and community patients were reviewing all tier 1 cases in good time. Almost all patients’ next of kin were contacted in the process where this was mandated. This enabled the trust to build a better understanding of how to support patient families or those integrally involved and take learning from their experiences.

Deaths were recognised if evidence showed they were potentially avoidable. The report went into detail about specific cases which had been subsequently investigated and what learning had been taken. In the 12 months from August 2024, 5 of the 12 deaths discussed in a clinical and professional review were deemed as avoidable. This had fallen from 9 in the previous year. The report went on to state how determination of a death as avoidable did not mean the death was necessarily caused by error or neglect, but care could have been improved from which learning could be drawn. The purpose was to strengthen process and not apportion blame. The area missing from the report was a review of actions taken previously to inform the board whether they had made a difference to future quality and safety of care.

The reports to the board contained sufficient detail to give assurance of learning and improvement where identified. The learning from death process included a review by a learning from deaths’ group. This included a multidisciplinary approach, and all specialities were required to attend and present learning from deaths, themes and key actions following any death within that specialty. There were several initiatives arising from the work of the group including: nutrition and hydration recording and monitoring; and the deteriorating patient and missed opportunities for early intervention. In respect of the latter, this was an area considered as of particular concern. A deteriorating patient steering group had been re-established to act in this area, and this was to include treatment escalation plan (TEP) discussions with the patient and family to improve communication and support.

The report included specifically, as required, deaths of patients with a learning disability. The trust also looked more closely at these deaths occurring in the latter half of 2024 and reported that although numbers were higher than typically seen (as it was for the national picture), there were no safety concerns or ‘red flags’ in care standards. Two areas not discussed by the learning from deaths’ group related to Coroners’ notices (Regulation 28 Prevention of Future Death reports) to provide assurance that learning had been taken when needed. Secondly there was a lack of assurance to the trust board that the duty to bereaved families and carers had been met in terms of their care and support, and involvement in any investigations.

There was learning and quick action taken around serious incidents. The trust had implemented the new NHS England Patient Safety Incident Response Framework (PSIRF). Staff told us it was challenging to implement but had settled now well. Staff at focus groups said they appreciated how the expectation of a PSIRF investigation was to look for learning opportunities and not to apportion ‘blame’. The trust’s governance leadership team described how a ‘swarm’ process would happen shortly after recognition of a serious incident. A ‘swarm’ was a process where key staff swarmed to the site to quickly analyse what happened and what needed to be done to reduce risk. This enabled areas of concern to be addressed while the memory of the incident was recent and not, as when formal investigations take place, often some months after the event. The lead for the swarm would use the NHS recommended SEIPS tool (this was a ‘system engineered initiative for patient safety’ tool) to organise the swarm huddle. Actions needed were then monitored. This process was, we were told, uniform across the trust with swarm and SEIPS being tools used for a several years.

Patient Safety Incident Investigations (PSII) reports were produced when indicated that learning could be gained from a serious incident. Those we reviewed (eight of 10 serious incidents were PSIRF – the other 2 following the old process) were detailed and comprehensive (the trust’s quality committee were advised in August that the quality of reports was improving). The patient (if appropriate) and families/carers were contacted to discuss any involvement they may wish to have in the investigation. Terms of reference were laid out as were the information that was to be gathered to complete the investigation. Key learning was identified which could be correlated with the areas of identified concern or failing. Key learning, improvement recommendations and safety actions were described.

The quality committee received a report covering serious incidents and latterly, now it was embedding, around PSIRF reporting. This reported the data in some details and described the tools used. Shared learning was reported by division, and some was used in the PSIRF newsletters. What was missing from this review of serious incidents was a section which confirmed (or otherwise) that actions for learning from serious incidents had been implemented effectively and was making the required difference. We were also concerned about the length of time some of reports had taken to reach approval after the incident happened. We recognise the complexity of some of these cases would require time and resources to review evidence. However, two case of the 10 we reviewed took 18 months to be finalised, another was 14 months, and a fourth just under a year. NHS England does not stipulate a time limit for PSII reports to be completed but expects the majority to be around 6 months but accepts others may be longer. Of those taking excessively long, and where harm had come to a patient, it was not clear in the investigation report whether there had been swarm or SEIPS undertaken where that would have been important for immediate learning.

There was learning from complaints, but without determining a correlation between the themes of complaints and areas for improvement. There had been a spike in complaint numbers in the 3 months of July to September 2025 (Quarter 2). This was up 70% on the same quarter in 2024/25 and almost double that of the preceding 3 months. Concerns raised to the Patient Advice and Liaison Service (PALS) were listed, but only in terms of numbers and how long it took to respond to them. There was no mention of themes or any considered learning. Although the quarterly report from the patient experience group determined which area or department of the trust had seen the sharpest increase or most complaints, it did not determine if there was a theme. There was no reason given for the increase seen in the last 3 months. There was learning from complaints described in some granular detail, but without any reference to themes from complaints, it was not possible to determine if this learning was meeting expectations of patients.

It was not possible to determine from the report if there had been improvement in the time to respond to complaints. The report concentrated on the response times in the 3 months of July to September 2025, and recounted the response rate as 70%, which was 20% below the trust required standard. However, the report only described this period, and it was not therefore clear if this was an improving or deteriorating picture.

People received comprehensive responses to complaints made to the trust. We reviewed 10 responses to complaints made in 2025 and responded to in October 2025. Each had addressed the specific requests about care and treatment made by the patient or their relative. They were fairly detailed in the response and where learning was found to be necessary, it was stated as being shared with the clinician or team. The trust quality committee papers indicated that any complaints which raised concerns about patient safety were taken up by the patient safety team, which we saw confirmed in one of the PSII reports we read.

The trust contributed to national audit programmes but was failing to comply with all required guidance. In the NHS national audit programme for 2025/26, the trust identified 76 audits it was required to complete. As at the end of September 2025, 12 audits were reported as a cause for concern around the data collection. It was noted how the resuscitation team had restarted the data collection for the National Cardiac Arrest Audit after not participating for around a year due to “resource limitations.” The trust contributed to the NHS’s 41 Group Priority Audits.

This was a rolling programme of audits around topics across the trust and undertaken in certain specialities such as the frequency of completion of resuscitation decisions and involvement of the frailty team in medical care; communication and consent in cardiology; and audit of safety procedures in dermatology and endoscopy. Four of the audits were overdue to start. An area of concern was around compliance with guidance from the National Institute for Health and Care Excellence (NICE). The trust’s quality committee was advised in September in a review of clinical effectiveness that the trust was only 18% compliant with its response to new NICE guidance. Action plans had been produced for the partially compliance guidance over the last 2 years. However, it was noted there was “no assurance on improvements against these action plans.”

The quality committee was provided with a report on clinical effectiveness (audits and guidance), but this contained limited assurance on reaching compliance and what the risk was for the organisation on failing to achieve compliance. There was also no reference to benchmarking against other organisations to determine if the trust was an outlier in some of these areas. For example, five of the six directorates had more than half of clinical guidance showing as out of date. This amounted across the trust to 304 out of 515 guidelines (59%). There was no clear plan proposed to resolve this problem, and the risk was not articulated or compared with the national picture or expectation.

In a study across trust committee papers, although there was a report on audit, this was around compliance, and we were unable to find any results of clinical audit to provide the trust board with assurance around clinical effectiveness. For example, following a never event in the emergency department in January 2025 (a never event being a wholly preventable incident), an audit of patient records showed a significant and concerning deficit in documentation in patient records reviewed. There was no evidence in the investigation report of how this would be further communicated so the board were assured through governance processes that this had been addressed.

In the pharmacy team, staff were clear about their roles and responsibilities. There were good governance, management and accountability structures around the safe use of medicines with lines of governance and medicine safety risks reported to the board. However, it was acknowledged that overall oversight could be further improved. From January 2026 a more formal assurance governance structure would be implemented.

In terms of a sustainable workforce the pharmacy senior management team and staff told us staffing was the biggest concern and risk for the sustainability of the service due to the challenges of vacancies within the workforce. For example, there was a lack of funding for recruiting staff (bands 2/3) who supported the movement of medicines across the sites. This increased the workload and pressure on other staff, particularly the operational teams who managed the weekend service as part of the 7-day funded pharmacy service. Staff told us staff shortages impacted on the wellbeing of staff; training of staff; study leave for staff; and booking annual leave. It was having a negative impact across the whole department with concerns that patient-facing services and the delivery of clinical pharmacy services were suffering and systems made this hard to quantify.

There was further concern for the ongoing provision of an aseptic and manufacturing service due to the imminent departure in January 2026 of the current responsible pharmacist. However, due to the time taken to approve the recruitment process there was real concern that there would not be a responsible pharmacist in post which would impact on the safe delivery of aseptic services for the trust. This was brought to the attention of the executive leadership team although no immediate response was provided.

Recent Care Quality Commission (CQC) patient experience surveys indicated areas requiring further action:

• Maternity Survey (2024, published 2025)
  • 39 of 57 questions were rated ‘about the same’ as comparable trusts.
  • No statistically significant changes compared to the previous year.
• Urgent and Emergency Care Survey (2024, published 2025) for type 1 service (AE)
  • 22 of 29 questions were ‘about the same’ as other trusts.
  • 5 questions were rated ‘worse than expected’, relating to:
    • Communication about tests.
    • Hospital environment and facilities.
    • Support when leaving AE.
  • Response rate was low at 19% (national average: 29%).
• Adult Inpatient Survey (2024)
  • Performance was ‘somewhat worse’, ‘worse’, or ‘much worse than expected’ in 29 of 46 questions.
  • 16 questions were ‘about the same’ as other trusts.
  • 6 questions were statistically significantly worse than 2023 results.
  • The survey period was within three weeks of MMUH opening, which may have influenced results, though patient experience concerns remained valid.

The trust reported results and themes from patient experience surveys in the quality committee of the board and identified the trust as a statistical outlier for some of the poor results. Divisional action plans were presented to the committee with progress indicated.

The Board Assurance Framework (BAF) was well-defined and followed a structured process. Each of the 5 key risks was aligned with the trust’s strategy and assigned to a relevant board member and committee. The BAF outlined:

• Strategic objectives affected by each risk
• Risk scores (initial, current, and target) and mitigation measures
• Links to the corporate risk register for consistency
• Assurance types for each control, assessed against their effectiveness
• Actions to address any weaknesses in mitigation.

The board received a detailed quarterly report, with risks refreshed by the accountable committee. This approach kept the BAF leader page clear and easier to navigate. The most recent review took place at the September 2025 board meeting, where the BAF and updated risk appetite statement for 2025/26 were approved.

There was a comprehensive report covering workforce data which enabled the board to gain assurance (or otherwise if the case) that many of the leading metrics around vacancies, turnover, appraisals, sickness and training were either meeting or close to objectives. There was sufficient detail to see possible emerging or new risks and areas for closer attention. The trust used statistical process control indicators to evaluate data, so there was sufficient clarity in the data to check for unanticipated variances or emerging concerns. The headline data was:

• In September 2025, the vacancy rate for all staff was 10.9%. This was on a falling (improving) trajectory but was still some way off the trust target of 9% and had not reached that level in at least the last 3 years. However, the peak in 2023 had been over 14% so progress had been made.
• To address the trust’s financial deficit, a workforce plan had approved the elimination of the use of agency staff. For September 2025, agency staff numbers had more than halved since April 2025 (122 reduced to 46) although costs remained high due to the continued use of medical locums. The trust had developed plans to mitigate this around substantive replacement of all locum posts.
• Time taken to recruit staff had been steadily reducing with the target of 67 days being continuously met or bettered since 2023. In September 2025 the number of days achieved was 59. This was the number of days since the post was approved on the recruitment system to the person starting in the new post.
• Sickness absence was above expectations but not significantly. In September 2025, the sickness absence rate was 5.9% (5.7% for the year to date). This was above the planned sickness absence rate of 5%. However, sickness was reduced when viewed over a longer period. It had steadily fallen from around 6.4% in 2022 to 5.7% for the year to September 2025.
• In September 2025, the 12-month rolling turnover for all staff was 9.5%. This was better than the target of 13%. This was on a falling (improving) trajectory from up around 14% in 2022.

Trust documents indicated and staff told us there was more work to do on the digital infrastructure and confidence in digital systems, including people resources. One area of concern for staff was around the number of patient electronic record systems being used across different parts of the trust. There were 4 systems in use in different services which did not all talk to each other. The team supporting the digital infrastructure did not have sufficient resources to provide a safe and effective service. For example, there were no or very limited staff involved in the clinical side of the digital work. There was no fulltime equivalent chief clinical information officer, no chief nursing information officer, no clinical digital trainers, and no defined clinical safety officer. This left the trust far short of what was considered as best practice in this area. There was one lead digital nurse and a digital midwife, but no one representing allied health professionals including pharmacy, and no subject-matter experts.

A report from the digital team highlighted, among other things, how the trust was at risk from staff being untrained in digital systems and a resultant lack of the ability to access training and reference guides which were mostly all now electronic. The trust board was aware there were clinical incidents reported due to staff being unable to use systems effectively. There were also some significant gaps in staff training in e-learning requirements. However, it was noted there was a risk on the corporate risk register which encompassed most of these areas of concern although with no progress reported.

There were processes to assess trust systems in the event of a security incident or system failure. The trust had an external report into its cyber assessment framework which was aligned to the Data Security and Protection Toolkit. The trust risk had been determined as high. However, the confidence level in the assessment the trust had made of its own risks was high. One of the areas criticised by the auditors was around the subject access requests policy which was overdue for review since either 2020 or 2021 (which year was uncertain). This was attributed to an issue with a contributor party to trust policies which should not have been used as a reason to delay this policy which no longer met the requirements for meeting subject access requests. The trust board were informed through information governance papers that this matter would be addressed by December 2025.

The trust did not fully meet its requirements to undertake Fit and Proper Person Tests for those in executive or other roles that met the inclusion criteria. However, the chief executive officer advised us following our feedback that the trust was going to immediately rectify the issues. As a health provider, the trust had an obligation to ensure only those individuals who were fit for their role were employed. The trust’s scope of those staff within the NHS England criteria met the requirements for all executives and non-executives acting as directors (or any interim or acting up to board posts) and should be included on appointment or in a regular review. The trust chair had approved the submission to NHS England that all legal requirements had been met in the most recent version which was for the year 2024/25. This was presented to the trust board in a public session in November 2025.

We undertook a review of a sample of the records held by the trust as evidence of its board members and others in the criteria were fit and proper. We found most were in order, although not all files were consistent in the information they held. However, one of the senior executives did not have an enhanced Disclosure and Barring Service (DBS) check. One of the non-executive directors had an enhanced DBS check which was not within the scope of the trust’s policy and therefore could be subject to a breach of GDPR. It was also held on file in contravention to DBS policy.

The self-declaration of the board directors were counter-signed by the deputy chair of the organisation in lieu of the chair but without at the time any delegated authority. The trust produced a scheme of delegated authority for the deputy chair following our inspection which was presented to the board by way of a ‘virtual’ paper. The trust’s DBS policy did not state whether DBS checks should be periodically updated or not. The policy also stated it complied with the DBS Code of Practice around confidentiality and stored all disclosure certificates for a period of six months. However, this practice does not accord with the Code and did not consider the certificate being the property of the applicant and not the organisation.

As we have reported above, the trust assessed its strategic risks through a board assurance framework complemented by the corporate risk register. The financial sustainability risk was by far the highest risk and had proved to be the least tractable. In relation to financial governance, trusts within the Black Country ICB were in the process of forming closer arrangements for joint working. The trust was in process of developing a group structure with Dudley Hospitals Group NHS Foundation Trust that would be implemented from 1 April 2026; and was an active member of the Acute Provider Collaborative (APC). Joint appointments were being made to the group board and closer shadow working through joint committees was said to be imminent. The APC was working together to harmonise ways of working including standardisation of policies and procedures to increase efficiency and effectiveness; and we were told there were plans to share certain corporate functions.

A decision had been made to retain a stand-alone Chief Financial Officer for the trust with the new appointee due in post in early 2026. The Acting Chief Financial Officer at the time of the inspection had been appointed in April 2024 and was a finance professional of seniority and standing.

NHS England (Midlands) had concluded, given the scale of financial challenge within the Black Country ICS in 2024/25, it had been important to place a common and consistent set of expectations on all key NHS partners in the ICS. The regulatory mechanism to do this was through an agreement of undertakings that applied to all trusts in the ICS. The trust had given commitments to deliver these undertakings for 2025-26 and monitored progress through its finance and productivity committee. The committee also received comparative performance of other ICS trusts.

The chairs of the finance and productivity committee, the infrastructure committee and the audit committee were all senior professionals with experience in public services. There was strong evidence of non-executive understanding of issues and risks facing the trust and a culture of constructive challenge. Committees had developed good governance practice by routinely reviewing the quality of assurance provided. The audit committee met with internal and external auditors in private both before and after every meeting. The committee was also developing a ‘register of sources’ of external assurance, which gave opportunities to test the consistency of assurance of the identification, management and mitigation of risk. This suite of local checks allowed the trust board to improve triangulation and benchmarking of its risk assessments with those provided by other external sources of assurance.

There was work to do to meet recommendations from the trust’s auditors. The external auditors had given the trust a clean audit opinion on its accounts for 2024-25 but had for the second year made recommendations to strengthen assurances about the trust’s financial sustainability. The trust’s internal auditor had given negative assurance on the operation of the trust’s internal controls for the year 2024-25, stating that there were weaknesses in the framework of governance, risk management and internal control such that it could become inadequate and ineffective. The auditor’s opinion was influenced not only but the numbers of reports providing minimal assurance but also the number of agreed management rectification actions that were overdue. The CQC inspection team was told internal audit reports for 2025-26 had given higher levels of assurance.

Senior leaders told us that to be assured services that were coming together in the new acute hospital could open safely, it had increased staffing levels temporarily. The trust’s financial plan for 2025-26 required significant improvements in productivity and efficiency, mainly through reducing its reliance on temporary and non-contracted workforce. Senior leaders told us, using national workforce metrics, the trust’s productivity was one of the worst in England, and that headcount had increased by around 22% (around 1,000 people) since 2018-19. The finance and productivity committee had undertaken in-depth reviews of performance against national data benchmarks, and we were told senior divisional leaders recognised the opportunities for improvement. However, clinical teams also told us staff vacancies were impacting on their ability to maintain the quality of services.

Senior leaders said they were preparing the trust’s medium-term financial plan. Outline guidance from NHS England had been shared through the finance and productivity committee and private board. However, we were told no consultation had yet taken place on planning assumptions and consequential service impacts.

The trust had established an infrastructure committee to take forward oversight of its estate, equipment and digital investments and realise agreed benefits. The opening of MMUH had given it the opportunity to rationalise its estate and make changes with partners to improve health and wellbeing of local populations through enabling, immediate, transformation, and regeneration benefits totalling £3.8bn. For 2024-25, the trust assessed that £193mn of ‘enabling benefits’ had been delivered. The estates strategy was being revised following the opening of MMUH and the release of empty land and buildings would allow capital receipts to be reinvested in infrastructure improvements.

The trust understood its duty to collaborate and work in partnership, so services worked seamlessly for people. Staff shared information and learning with partners and collaborated for improvement. The trust worked effectively within the community and understood the health and care system landscape as an integrated trust with acute, community and primary care services within its service provision. The trust was often front and centre of community projects and driving multiagency working.

Our findings:

The trust board understood its duty to collaborate with communities, key stakeholders and work in partnership and strategically with other health and social care organisations and local authorities. This included both providers and commissioners of health and social care. As we report more on below, there was also partnership working with key stakeholders around the environment, net-zero carbon emissions and sustainability.

The trust’s strategy was mirrored with that of key stakeholders. One of the significant relationships for the trust was with the integrated care board (ICB) for the Black Country Integrated Care System (ICS). The ICB’s key strategy around population health and wellbeing (Integrated Care Strategy) was published in 2023. Trusts were required to align their annual plans with those of the joint forward plan (JFP). The most recent iteration of the JFP for the region contained 6 key strategies, namely:

• Improving access to and quality of services

• Community where possible, hospital where necessary

• Preventing ill health and tackling health inequalities

• Giving people the best start in life

• Making the Black Country the best place to work

• Making the system fit for the future.

Part of the focus from the ICB in collaboration with the trust was around integration. The local teams were working closely with the ICB’s ‘place committees’, and collective work programmes in areas such as urgent care, diagnostics, maternity and primary care, among others. The trust also recognised the move to ‘neighbourhood working’ as outlined in the NHS England Neighbourhood Health Guidelines issued in January 2025. The trust board were informed about the requirements of the Guidelines to structure future plans around:

1. Population health management

2. Modern general practice

3. Standardising community health services

4. Neighbourhood multidisciplinary teams

5. Integrated intermediate care with a ‘home first’ approach

6. Urgent neighbourhood services

The trust strategy covering partnership and community working, as reported above in our section on shared direction and culture, linked to the strategic national commitments. The trust had a flexible approach as well to longer term strategic objectives and these could be updated if national or local priorities shifted.

Staff and leaders understood the need to engage with partners to share learning and results in continuous improvements. The trust’s CEO was a partner member of the ICB representing acute hospital trusts. They were the ICS lead for cancer, elective care and diagnostics. They were also the senior responsible officer for acute provider collaboration across the Black Country.

The trust used networks to identify new or innovative ideas that could lead to better outcomes for people. A provider collaborative clinical summit was held in November 2025 in which they trust participated and where colleagues from all the regional NHS trusts, the ICB and NHS England local and national teams came together. This gathering looked at ways to improve efficiency from working more closely together and showcased projects improving patient outcomes. This included work on a shared clinical pathway for breast reconstruction. One of the objectives was to bring patients closer to home for this surgery to improve patient experience.

There were objectives to support people with neurodiversity. The trust had worked with a local neurodiverse creative collaborative to design and build a new community garden space with a focus on the needs of people with a learning disability. There was close partnership and collaboration with other providers such as the mental health trust around pathways and policies for supporting and caring for people with a learning disability. The team at the trust who supported people with a learning disability were engaged throughout the trust with different teams and specialities to educate and support staff to give the best care. This extended to trust staff with experience of supporting children and young people with mental health needs and helping parents or guardians to navigate the system.

Trust staff also worked together with community healthcare staff through weekly meetings to set up strategies for supporting patients in the community following treatment in the acute hospital. This had resulted, we were told by the staff supporting people with vulnerabilities, in staff feeling more competent and valued. The staff were more compassionate. There was a reduced length of stay for these patients and reduced deaths were seen. Patient care was more personalised and complaints were reduced. Staff could articulate issues far more easily and saw patients not as a ‘problem’ but someone with unmet needs.

The trust advertised the local food charity shop for NHS staff and the local community. This was located across the road from the Birmingham and Midland Eye Centre at City Health Campus and was for food donated by supermarkets with short expiry dates and sold at discounted prices to cover operating costs. The trust also worked alongside the Birmingham and Lewisham ICS to address barriers to health for African and Caribbean communities. This involved developing cultural competency training for staff and establishing social prescribing groups to bring together parents, healthcare professionals, local authorities, and community partners. The trust also worked with other community groups, notably:

• The trust was a member of the Birmingham and Solihull ICB Health Equity Collaborative, alongside children’s charitable trusts. This supported improving outcomes for children and young people.

• Bi-monthly Iman group meetings with local faith organisations, the police, colleges, food banks, and the local authorities to discuss issues affecting the Muslim community and wider faith communities in the area.

• United Reform Church – Handsworth social prescribing group. This was work with local GPs, midwives, and local partners to address the social isolation for some people and barriers around access to community services.

There were opportunities for patients and people in the area to become involved with the trust. The trust’s ‘Engage’ group was a membership of local people who were also part of the Patient, People and Population Voices work. This was designed to hear from the local population and their experiences of health and care. They received welcome packs and quarterly newsletters and invitations to attend Engage events. There were currently around 1,000 members. The work with younger people included Youth Space which was an opportunity for people aged 13 to 21 to give their input into services and learn more about how health and care works. This included around 80 young people being involved in a piece of work each month. This had included inspections of children’s wards, and putting together views on Martha’s Rule (the recently introduced rule which enables people to have a second opinion about their care and treatment). The Youth Space had also worked on the multi-generational “anti-boredom box” initiative, connecting young and older people.

The trust had a group of dedicated volunteers at each hospital site. They were clearly valued and a great support for staff and patients. However, there were some concerns around support for the volunteers we met at MMUH which we reported back to the trust to urgently tackle. The trust also worked with charities and partners to provide patient services. This included shops within the hospitals and opportunities with the chaplaincy service.

Although the MMUH had been open around a year when we conducted the onsite part of our assessment of the trust, this had not happened without a considerable amount of work by the engagement team. The team had been required to prepare staff and around 750,000 people in the local area for the opening of the MMUH and the subsequent closures of the emergency departments at Sandwell and City Hospitals (the department was established at the new MMUH). The team worked with local people such as faith leaders and shopkeepers to enable good conversations to happen with communities. The team had been shortlisted for an award with a healthcare journal in the Communications Initiative of the Year category.

The trust worked with multiple partners across health and social care and education and training, research and clinical trials. It also worked with private companies in projects and education. The trust was a partner organisation for Birmingham Health Partners – a group of academic and healthcare organisations across the West Midlands focusing on research and clinical trials. This included the University of Birmingham, Aston University, local NHS trusts working in the acute, community and mental health services, and Health Innovation West Midlands.

In pharmacy services, there was good collaboration and partnership working to ensure information was shared between services with a strong working relationship with the ICS in the Black Country. There was joint working in the prescribing incentive schemes with the ICB for medicine optimisation, a joint formulary group, and a joint medicine safety group. This helped to support and improve patient outcomes with access to medicines and shared care issues.

The pharmacy team recognised more work needed to be done to improve engagement and feedback from patients. Current feedback was obtained reactively when things did not go well such as through complaints. This was aligned to the pharmacy strategy and had been identified as a project for 2026 alongside the patient experience team. The pharmacy team were involved in improving the speed and safety of the discharge of patients. The discharge medicines service was started in February 2025 and included reviewing any medicines related issues for patients in the community. A dedicated electronic contact group was set up for the discharge lounge, discharge hub and virtual wards to allow the direct escalation of priority medicines required at discharge and improve the communication of any issues.

The trust had an informative website with access to a library of resources and live information. The website could be translated into any language, although it was not overly clear how this could be carried out (it was through a toolbar called ‘Speak’ which provided access to translating the text on a page through a series of icons). However, where any reports were published on the trust website, a flaw in the software used meant some diagrams or charts used were distorted and unable to be read.

The trust supported continuous learning, innovation and improvement. There were processes to apply learning when things went wrong. Staff were supported to develop their skills and were constantly encouraged to contribute to innovation. Staff and leaders were engaged with research, development and innovation. Mandatory training and appraisal compliance rates were good.

However, a theme came from staff focus groups which described how staff at times found it hard to access training and development due to being overtaken by clinical or other priorities. There needed to be improved examination and reporting of the achievements of research and development at the trust.

Our findings:

There was an active research and development (RD) team involved in and having completed many projects over the years. The team had a 5-year strategy covering 2023 to 2027 titled “Improving Lives Through Research”. It had 4 key workstreams, namely:

• Leading areas of research

• Patient and public involvement and engagement

• Provide an outstanding research and development department

• Enable all staff to be part of research.

One of the key metrics in research was from the number of people who were recruited to take part. The trust had a target of at least 2,500 people being involved in projects in each of the 5 years. This was achieved and exceeded in years 2 and 3 but, possibly, would not be achieved in 2025/26 due to the end of a high-number participant study. However, other studies were planned which could have high numbers of participants (one around type 1 diabetes). The trust was meeting the target to generate commercial income to invest back into staffing and infrastructure for research.

The trust board were informed regularly about progress in RD against both the strategy and 24 measurable achievements under each of the 4 workstreams. However, what was missing from the reports to both the trust board and the quality committee was a comprehensive review of what research was being undertaken, what had been completed, and importantly, what difference it had made to patient care and treatment. The heads of RD told us about various studies including national statin trials, research around Lupus, a new device for cardiovascular screening, and prescription of ethanol for alcohol misuse. The RD team organised study time for staff around research and met with senior executives to update them on their work. However, this detail did not inform board papers (we reviewed those over 6 months) or the quality committee (we reviewed those over 3 months). There were papers presented, but not in relation to the achievements of RD and how it had benefitted people and the community. Nevertheless, there were ‘thank you’ events for participants, a Red for Research Day (sites lit up in red and red shrubs planted by staff and research participants), and some impressive plans for the future (including bidding for 2 mobile units for research purposes in the community).

There was some, although limited information on the trust website about RD but little to describe achievements to date. There was, nonetheless, good partnership working with, for example, the National Institute for Health and Care Research, and the local universities. The team had its own clinical research facility at Sandwell Hospital which had 10 clinic rooms including a dedicated room for children and young people, and laboratory space.

The trust responded well when an incident relating to research was identified around the failure to gain valid consent from participant patients from an historic study with one of the local universities. The quality committee had received a full report on the investigation into the matter. Actions had been taken in accordance with the requirements of regulators, and the matter would be closed when it was finally concluded. There was no evidence of harm to patients or impact on the care received.

In certain individual programmes or teamwork staff applied a quality improvement lens to a wide range of topics and areas needing improvement. This included, for example, learning from death, environmental sustainability, the deteriorating patient, maternity services, dermatology induction, and a project on hypoglycaemia. However, the trust was aware and open that a cohesive strategy and consistent approach was needed for quality improvement, and external partners had been engaged to provide a direction. The board or quality committee did not receive a report focused on quality improvement programmes from the team responsible for the initiatives, which made it difficult for assurance of its effectiveness to be understood.

In pharmacy, there was a positive culture towards continued improvements. Overall, staff felt the pharmacy senior leadership team encouraged innovation and progression. With the move to the new MMUH site there had been several innovative projects with efficient, safe and timely supply of medicines as the focus. For example, a new process for closed loop medicine administration, and a new fully automated stock management system had been introduced.

There was a comprehensive training programme for staff with a focus on career development. This included the standard subjects in mandatory training, but went on to include apprenticeships, work placements (work experience), organisational development, and leadership and management courses. The trust was also linked in with the training available in wider NHS resources. The courses were designed for both clinical and non-clinical staff, and those in non-management or supervisory roles. There was a range of IT skills training offered, which extended to include commonly used software packages.

The trust’s leadership programme, known as the ARC leadership programme (ARC being the trust values – ambition, respect and compassion) was aimed at providing skills for managing people. It was launched in 2023 around three modules linking to the cultural components of the trust’s people strategy. The first part of module 1 enabled staff who were not in a management role to participate in a session called ‘compassionate caregiver’. This was for staff to consider how the trust’s values could be expressed when working with colleagues, patients and the public. There were also a range of standalone courses covering HR topics for new managers or refresher courses and help with functions not considered as ‘everyday’ for many staff. This included workforce planning, how to produce board and committee papers, and recruitment system training, among many others.

The trust was an accredited apprenticeship training provider. Courses funded included apprenticeships for healthcare support workers (and senior HSWs); business administrators; and team leaders. There was also a wide range of other options for staff to apply for with external training organisations which would be funded by the organisation if approved. These extended to clinical roles such as dietitians, physiotherapists, and a registered nursing degree among a whole range of clinical roles. There were also non-clinical roles such as data analyst, assistant accountant, and coaching executive, again among a long list of options.

The trust board were provided with a progress report on learning and development. The report from August 2025 stated that 1,214 staff had already engaged with the elements of the ARC programme. Of those, 891 frontline staff with no managerial responsibilities had completed the compassionate caregiver course. The most recent evaluation of the courses from attendees (62% response rate) reported almost all staff giving positive feedback with 99% saying the course was useful, enjoyable and they would recommend it to others. Sometime later, delegates were asked if they had made changes to their behaviour because of attending the programme and 74% said they had. For the 2025-26 financial year, 720 training places were planned for the part 1 modules with 600 for parts 2 and 3.

Most staff we met agreed there was an excellent programme of training and development at the trust. However, almost all of them said they were able to find less time to take part in the courses on offer. They told us the major concern for them was with staffing levels and with managers needing to work clinically increasingly to pick up unfilled shifts. They said this impacted significantly on training opportunities. Some had to cancel courses booked at the last minute as they would otherwise be cancelling clinics or patient’s appointments. They said staff were pulled away from training too often to return to their usual duties.

The 2024 NHS Staff Survey supported views of improvements in this area with most of the following indicators around learning and development improved over the past 4 years since these questions started. However, they all remained just below the peer group:

• Q24b: 52% of staff said there were opportunities for them to develop their career. This was 2% below the peer group average for 2024 and the response had remained much the same in the 4 years since the indicator had been added to the survey in 2021.

• Q24c: 67% of staff said they had opportunities to improve their knowledge and skills. This was also 2% below the peer group average for 2024 but the best result in the in the 4 years since the indicator had been added to the survey in 2021 (up 3% in 4 years).

• Q24d: 55% of staff said they felt supported to develop their potential. This was slightly below the peer group average for 2024 at 56% but the best result in the in the 4 years since the indicator had been added to the survey in 2021 (up 5% in 4 years).

• Q24e: 58% of staff said they were able to access the right learning and development opportunities when they needed to. This was slightly below the peer group average for 2024 at 59% but also the best result in the in the 4 years since the indicator had been added to the survey in 2021 (up 6% in 4 years).

In terms of staff being given the opportunity to discuss their role, their performance and future opportunities at an annual appraisal of their work, the 2024 NHS Staff Survey showed there was more to do in this area. In 2024, 76.5% of staff said they had an appraisal (peer group average 85%) which was up from 74% in 2023 but far lower than 2021 (when the measure started) at 89%. However, only 25% of staff said this helped them improve how they did their job. Although this was an area of concern across the NHS as this was almost the same as the peer group average of 26%. However, it was up from 2021 (when the measure started) by 6%. The question around the appraisal helping with clear objectives for staff was steadily improving as was the recognition of the work of staff being valued by the organisation, although both still at low levels – and the same as the national average of the peer group.

The trust was meeting the NHS England requirements around appraisal and validation of medical staff. This was reported through a compliance statement provided to NHS England and validated by the trust’s people committee in early October 2025.

Appraisal rates were improving. For staff overall, the appraisal rate for September 2025 was reported as 89.6%. This was almost achieving the trust target of 90%. The trust measured appraisals from a zero reset at the start of the financial year, so was on track to exceed the trust target in the coming months.

For mandatory training, the trust had good compliance from staff although not quite meeting the trust target. In September the compliance rate was 93.6% which just fell short of the 95% target. The trust had not been above target since February 2024, although had a more ambitious target of 95%, with other comparable trusts at 90%.

The trust understood any negative impact of its activities on the environment and strived to make a positive contribution in reducing it and support people to do the same. There were many programmes of work and schemes undertaken or planned which would make a positive impact on environmental sustainability. However, some key areas around use of utilities such as gas, electricity, and water were missing from the trust’s assurance papers and risk registers.

Our findings:

Staff and leaders understood the threat from climate change and were taking action to reduce the impact on the environment of healthcare activity. The trust and its staff had a genuine commitment to reduce the significant threat to the health of people who used services, their colleagues, and the wider population.

In October 2020, the NHS became the world’s first health service to commit to reaching a carbon footprint of net zero by 2040 for the emissions it controlled directly. The ambition is to reach an 80% reduction by 2028 to 2032. For those things the NHS can influence rather than directly control, the target is net zero by 2045 (80% is the ambition by 2036 to 2039). This was embedded into legislation in July 2022. The trust had aligned its plans with these ambitions. The NHS Long Term Plan included commitments related to health and the environment, including around climate change, reduction in use of plastics, particularly single use, improving air quality, and minimising waste and water use.

To deliver this ambition, NHS trusts were required to focus on 2 primary actions:

• Enable and produce direct interventions to reduce waste and carbon dioxide emissions within estates and facilities, travel and transport, supply chain and medicines.

• Take actions to improve levels of waste and emissions, accelerate sustainable models of care (such as care closer to or at home), workforce impacts, networks and leadership commitments, and funding and finance mechanisms.

As required by NHS England, the trust had developed its 2025-2028 Green Plan, which replaced the earlier plan from 2022-2025. The Green Plan was required to include aims, objectives and delivery plans for carbon reduction and sustainability. The plan was presented to the board in September 2025, and the board were advised it would be overseen by the trust’s infrastructure committee before submission to NHS England in October 2025. In a review of previous trust board papers for the year 2024, it was apparent the board had not had sufficient oversight of the plan in previous years as it had not been discussed by the board. However, this subject was now being picked up by the infrastructure committee led, as required, by a non-executive director to oversee this subject for the board.

Importantly, the board noted how the new 2025-2028 plan aligned with the plan for the integrated care system to ensure people were working to the same aims and objectives. The Green Plan and its initiatives had been developed, as it would need to be, with a range of local health and social care providers and stakeholders. This included the local authorities, the Integrated Care Board, West Midlands Combined Authority, local universities and colleges, Birmingham Clean Air Coalition, and other health and social care providers and partners across the Sandwell and West Birmingham region.

The trust had set priority sustainability objectives set around 9 specific areas of focus. These were:

• Our people, workforce and leadership

• Estates and facilities

• Travel and transport

• Medicines

• Food and nutrition

• Net zero clinical transformation

• Digital transformation

• Climate change adaptation

• Supply chain and procurement

There was progress in several key areas. NHS England had provided the trust with measures of carbon emissions covering the 5 years from 2019/20 to 2023/24. This excluded business travel and fleet data as this had not been gathered for the last 2 years. The trust was reported as having achieved reductions if 5.7%. To meet the net zero target, the trust reported needing to achieve 7.1% in future years.

The team we met to discuss the subject of environmental sustainability showed commitment and enthusiasm. The trust infrastructure committee led on delivery of the green plan. The committee met every 2 months with a 6-monthly focus on the green plan. The committee was supported by a green plan working group which met every 3 months and included external partners particularly those involved with estates and facilities. There was further involvement across the trust’s governance structure from the groups we would expect to see involved namely: digital transformation, travel and transport, clean air, wellbeing and biodiversity, energy, estates, waste and recycling, food and nutrition, and clinical transformation, medicines and supply chain.

The trust had made inroads in securing funding from government grants for environmental schemes. The trust was allocated a share of £12.5m of the NHS Public Sector Decarbonisation Scheme (PSDS) Phase 3C Update for heat decarbonisation and energy efficiency measures at the Sandwell Health Campus. This will go towards installation of a heat pump system, replacement of windows, roof insulation, and replacement of all lighting with LED energy-efficient fittings. The trust had successfully bid for NHS Energy Efficiency Fund funding of around £838,000 for solar panel schemes, LED lighting upgrades, and building management system upgrades.

There were several actions already showing results. This included:

• Installing electric vehicle charging points across the estate. This had supported 589 drivers and saved 91 tonnes of carbon. Taking delivery of 5 electric fleet vehicles.

• Working closely with a bus company to promote increased use of regular bus transport. All new staff were provided with a 4-week free bus pass and there were other offers available for staff and patients to have free or discounted bus fares.

• Organising sessions to engage colleagues on the importance of assessing asthma inhaler techniques and prescribing.

• Ensuing all sites use only one of the lowest carbon inhalational anaesthetic gases and removed desflurane and isoflurane from use (two of the highest carbon anaesthetic gases). Total emissions from anaesthetic gases had reduced by 68% in the five years from 2018/19. The trust had also stopped piped nitrous oxide use at Sandwell and City sites.

• Moving to the use of more environmentally friendly packaging in catering. Stopped purchasing single-use plastic stirrers, straws, cutlery and plates unless there is a clear clinical need.

• Creation of an outdoor gym at City Health Campus.

• Stopping the use of unnecessary products such as red drug-round aprons, theatre warm-up gowns, single-use tourniquets, and single-use kidney dishes. Changed to using reusable baskets made from polymer carrier bags.

In line with recommendations, the trust’s operating theatre teams had moved away from many single use items. Some of these included sterile gowns, with reusable gowns saving £36,000 a year and reduced plastic waste. Around 50,000 single-use blood pressure cuffs were removed from use saving carbon and £65,000 a year. Reusable curtains were provided along with reusable bronchoscopes, sharps containers, tourniquets, and plastic jugs and bowls. Savings of around £400,000 have been made in stock holding by reducing the number of products used and achieving £140,000 reduction in waste from products expiring before being used.

Staff were included in programmes of work around environmental sustainability. The trust had a network of volunteer staff in its Green Impact programme. Departments participating in Green Impact had at least one member of staff taking the lead on sustainability. There were plans to run ward accreditation schemes with sustainability as a feature; encourage staff to complete an e-learning module based on environmental sustainability; and share best practice and ideas. One area staff had made a significant contribution to the reduction of carbon emissions was from 1,471 now using the bus as transport to work when they typically would not have done so. It was noted staff awards now included environmental sustainability initiatives.

Waste segregation was improving as was the use of paper. Prior to the opening of MMUH, the trust was some considerable way from meeting NHS England’s ‘20:20:60’ clinical waste strategy of 20% incineration (most carbon intensive); 20% alternative technology (non-burn or low temperature); 60% offensive (least carbon intensive). Various actions were taken to shift the position in January 2025 from 10% incineration; 60% alternative technology; and 30% offensive. This had shifted by September 2025 to 15:32:53 with each strand moving in the right direction. The use of paper had reduced by around 60% in the five years from 2019/20.

The new MMUH estate had been built with a strong focus on sustainability. This included the use of intelligent LED lighting, solar panels, and combined heat and power systems to reduce carbon emissions. Policies, practices and programmes of work were required to undergo a sustainability impact assessment. Deep cleaning was undertaken with UV-C light rather than HPV (hydrogen peroxide vapour) which eliminated the use of chemicals, risk of inhalation, and was safer for both the staff, patients, and the environment.

The trust had developed its own tools to support staff to make decisions for product use based on sustainability criteria. The tool would require the user to state what the product was, the size, the weight and what it was made from. It would then compare two otherwise similar or equivalent products and determine which was the ‘greenest’ (had the least impact on the environment.

However, there were several key areas which had not been reported through the latest green plan or board papers, including risk registers. This included omission of the use and cost of gas and its emissions and the use and cost of electricity. There was no mention of the procurement of renewable energy. Although digital was touched upon, such as the move to virtual appointments for patients, the Green Plan was said to be closely linked to the trust’s digital strategy itself said to be committed to delivering a green agenda. The digital strategy was not a published document, and the ‘group digital plan’ discussed at the November 2025 board meeting, did not mention environmental sustainability. There was also no mention in environmental sustainability papers of the use of water and water conservation and any equipment used for the rapid identification of potential leaks. The trust’s Green Plan described the risks to achieving its ambitions, but these were not graded to focus on priorities and provide the board with assurance of good governance around risks. None of the risks were reported through the trust’s corporate risk register. Some that had been included, such as risks to the estates strategy caused by insufficient capital resources, did not reference the risks to environmental sustainability or the objectives of the green plan.