Black Country Healthcare NHS Foundation Trust

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

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

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

The trust had effectively communicated its vision and values to frontline staff. We heard that the trust’s CARE values – Compassionate, Accountable, Respectful and Empowered – were introduced during staff induction and reinforced through newsletters, email communications and the trust’s intranet platform. Several staff we spoke to were able to recall the CARE values and describe how they related to their work.

The trust recognised that the culture within staff teams could have a significant impact on the quality of patient care. We heard about the introduction of a ‘Behaviour Charter’, which set out expected standards of behaviour and linked these to the Trust’s values, helping staff understand what behaviours were considered acceptable and unacceptable.

The evidence showed some shortfalls. Although many staff spoke positively about their immediate managers and team culture, some staff did not feel adequately consulted about decisions affecting them and felt support following incidents was not always consistent.

Most of the staff we spoke to reported feeling well supported by their line managers and colleagues, describing a positive team culture and a strong sense of teamwork. Several staff also told us that the trust was a good place to work. Communication within the multidisciplinary team was reported to be strong and well established. Some staff spoke positively about the visibility of senior leaders, noting that the trust’s Chief Executive had recently visited Bushey Fields and had engaged well with staff, helping them feel connected to the wider organisation.

However, some staff felt that support from management following incidents could be improved. In particular, they told us that they would value more consistent debriefing, support, and access to additional training where appropriate after incidents had occurred.

Several staff reported that they did not feel adequately consulted about changes to break allocations and the implementation of annual leave and carers’ leave policies and felt there had been limited opportunity to contribute to decision-making.

The evidence showed some shortfalls. Staff awareness of the Freedom to Speak Up process was inconsistent. Staff did not always feel confident that they could raise concerns and be listened to without fear of repercussions

The trust had 2 Freedom to Speak Up (FTSU) leads supported by a network of FTSU champions across its sites. Information about the service was shared through staff induction, emails and posters.

Between January and May 2026, 58 FTSU cases were raised across the trust. Concerns most commonly related to staff safety, staff behaviour, organisational processes and patient safety. Recurring themes included bullying, intimidation, psychological safety, delays in management responses, inconsistent investigations, limited wellbeing support and perceptions of unfair treatment, particularly among bank staff.

Staff awareness of the FTSU process varied. Some staff were able to describe the process and identify local champions, while others demonstrated limited understanding of how concerns could be raised.

Several staff reported positive experiences and felt supported when using the service. However, some staff remained reluctant to speak up due to concerns about potential repercussions. One staff member told us they felt they needed to be careful about what they said because they were worried it could affect future references.

The trust monitored speaking-up arrangements through six-monthly reports presented to the Board. These reports showed that staff continued to use FTSU routes and that confidence in speaking up was improving. However, they also identified a gap between staff willingness to raise concerns and confidence in how the organisation would respond. Key areas for improvement included the timeliness of responses, visibility of outcomes and strengthening psychological safety.

The trust had also developed a Freedom to Speak Up Gap Analysis Tool to identify weaknesses in existing arrangements and monitor improvement actions. This demonstrated an ongoing commitment to strengthening the effectiveness of the service and supporting staff to raise concerns.

The evidence showed some shortfalls. Some staff felt workplace policies and arrangements did not always provide sufficient flexibility to support caring responsibilities and personal circumstances.

The trust undertook equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the patient group.

Several staff raised concerns about recent changes to annual leave, emergency leave and carers’ leave arrangements. They felt there was little flexibility when unexpected situations arose, such as medical appointments, caring responsibilities or emergencies at home. For example, one staff member said they had been recorded as absent when attending a blood test appointment, despite agreeing to work an alternative shift, while another described being unable to take leave to deal with a broken boiler during winter unless a colleague agreed to swap shifts. Some staff said they were unable to use emergency annual leave or carers’ leave and felt that taking sickness absence was sometimes the only option available to them.

Following the inspection, the trust provided further information regarding how concerns relating to annual leave, emergency leave and carers' leave arrangements had been considered and addressed. However, staff feedback obtained during the inspection indicated that some staff experienced difficulties accessing flexibility when unexpected personal, medical or caring circumstances arose.

The evidence showed significant shortfalls. Governance systems were not operating effectively to identify, monitor and address risks. Leaders could not always demonstrate that governance arrangements provided effective oversight of quality, safety and performance, resulting in repeated failures across multiple areas of the service.

The service had governance arrangements in place, including risk registers, quality and safety meetings, incident reporting systems and multidisciplinary team meetings. Risks were discussed through established governance structures and leaders monitored performance through a range of assurance processes. Staff had access to electronic patient records and incident reporting systems, and learning from incidents was shared through quality and safety groups, serious incident reviews and thematic reporting.

However, despite these arrangements, governance systems were not always effective in identifying, escalating and addressing concerns in a timely manner. During the assessment, significant issues were identified in relation to medicines management, safeguarding, risk management, staffing levels and environmental safety, several of which resulted in breaches of regulations. These concerns were identified across multiple wards and sites and demonstrated a disconnect between governance processes and frontline practice, reducing assurance that governance systems were operating effectively.

We found examples where governance and oversight processes had failed to identify or address concerns promptly. Incident reports indicated that risk assessments and care plans had been updated following incidents, yet record reviews showed this had not always occurred. Safeguarding incidents that met referral thresholds had not been referred appropriately, and medicines management processes were not consistently followed, including in relation to insulin prescribing, valproate monitoring, medicines storage and stock management. Environmental concerns relating to fire safety, ligature risk management and longstanding maintenance issues remained evident across several sites despite established monitoring arrangements.

Although risks were discussed through governance processes and many of the concerns identified during the assessment were known to the organisation, actions were not always embedded effectively or monitored sufficiently to ensure sustained improvement. For example, staff continued to report significant delays in addressing maintenance concerns, awareness of ligature risk assessments was inconsistent, and weaknesses in incident follow-up and safeguarding practice remained evident despite previous improvement activity.

The assessment also identified concerns regarding the reliability of information used to monitor service performance. At the MacArthur Centre, information relating to delays in patient discharge was inconsistent with evidence gathered during the inspection, reducing assurance that leaders were always receiving accurate information to support decision-making and oversight.

The evidence showed a good standard. The service understood their duty to collaborate and work in partnership. They shared information and learning with partners.

Frontline staff and service leaders engaged regularly with external stakeholders, including commissioners, community mental health teams, the local authority and probation services. The Trust held regular meetings with stakeholders to provide oversight of areas such as patient care and contract monitoring.

Many patient records showed evidence of staff working collaboratively with external agencies and community mental health teams to ensure patients’ care and support needs were considered during their admission and when planning for discharge. This included liaison with external social workers. Patients we spoke to also confirmed that external agencies were involved, particularly when planning their discharge.

The evidence showed a good standard. The service promoted continuous learning, innovation and improvement. It developed and tested new approaches to improve patient outcomes, experience and the quality of care provided.

he service participated in a range of quality improvement projects aimed at enhancing patient care and outcomes. These included an ‘Emojis’ emotional monitoring project, which enabled patients to record their mood before and after group sessions to support emotional awareness and reflection. The service was also involved in an exercise-based project developed in partnership with a university to explore the impact of physical activity on mental wellbeing and reducing violence. In addition, the trust was developing a quality improvement project focused on improving the quality and consistency of care plans.

The trust had completed other improvement initiatives, including work to embed Culture of Care standards across inpatient mental health services. Audits had also been undertaken to strengthen the assessment and management of patients with co-occurring mental health and substance misuse needs, including improvements to urine drug screening processes and medical assessments.

The trust demonstrated a commitment to research and innovation through participation in a range of studies. These included GameChangeVR, which explored the use of virtual reality in therapeutic interventions, and biomarker research aimed at improving understanding and treatment of mental health conditions.

These initiatives demonstrated an ongoing commitment to improving care, adopting innovative approaches and contributing to the development of mental health services.