The Care Quality Commission (CQC) has again rated Nottinghamshire Healthcare NHS Foundation Trust as requires improvement for how well-led it is following an inspection in September.

The trust delivers integrated care services, including inpatient, community and high secure mental health, learning disability, and physical health services. The trust employs over 11,000 staff work and provides services in a variety of settings from over 250 different locations, delivering care to a population of around 1.1 million people.

Between May 2024 and August 2025, CQC has carried out a programme of 39 inspections at Nottinghamshire Healthcare NHS Foundation Trust. This was part of recommendations CQC made during its formal review, commissioned by Secretary of State for Health and Social Care, of Nottinghamshire Healthcare’s services following the devastating attack carried out in June 2023 by Valdo Calocane.

Inspectors carried out this trust-wide well-led review following these service inspections to assess the trust’s leadership. During this inspection, CQC identified breaches of regulation relating to how the trust was managed and has told the trust to submit an action plan showing what immediate and widespread action it is taking in response to these concerns.

The CQC last rated how well-led the trust is as ‘requires improvement’ in an inspection using its previous methodology for trust ratings.

The CQC currently gives NHS trusts a single trust-level rating focusing on leadership and culture that replaces all other ratings at that level. CQC is consulting on this approach following recent feedback from those in the sector and learning from the reviews by Dr Penny Dash, Professor Sir Mike Richards and the Care Provider Alliance.

Ceri Morris-Williams, CQC deputy director of mental health in the midlands, said:

“During our inspection of Nottinghamshire Healthcare NHS Foundation Trust, we found the trust hadn’t made specific improvements we had told it to make at a previous inspection.

“While there were some positive areas where the trust was progressing, we found senior leaders needed to prioritise essential improvements and embed a positive culture and strategies across the organisation.

“People supported by the trust were generally positive about the care and treatment they received from some services and staff. They were happy with their interactions with staff and had positive experiences, and staff made them feel involved in their care and support. However, some people told us they had more negative experiences of staff who weren’t compassionate or professional. They also highlighted issues accessing mental health services and long waiting times, and didn’t feel involved in decisions about their care.

“In 2022, we told the trust to make significant improvements and remove shared living, dormitory style accommodation. Leaders hadn’t been proactive in completing this work, and as a result we’ve told them to take immediate action to remove this accommodation and prioritise improving the estate and environments across its services. We found this to be in breach of regulation relating to how well the service is managed.

“Due to the level of concern, around this breach and others breaches we identified,  we asked the trust to submit an action plan that addresses how they will embed and make progress on its shared vision and strategy, a strategic culture to deliver workforce equality and diversity, and the Patient and Care Race Equality Framework (PCREF).

“Members of the trust board didn’t have the shared vision to drive changes and improvements and achieve the trust’s goals. We found the board didn’t always work together in a collaborative way.

“We have told the trust where they need to make immediate and widespread improvements, and we will continue to monitor services to make sure people are safe while this happens.”

Inspectors found:

  • While senior leaders spoke positively about improving trust culture, they hadn’t consistently taken action to make this happen. For example, one of the risks in the board assurance framework recognised that staff’s experience at work was poor, which was leading to poor engagement and higher levels of absence and turnover which impacted on people using services. However, the board assurance framework’s language focused on attributing responsibility to staff for this risk and hadn’t recognised the negative language and its potential effect this could have on staff morale, and how this directly contributed to poor culture.
  • Leaders didn’t have a shared vision or strategy to consistently drive forward effective change and the strategic goals of the trust.
  • The trust had the right skills and resources in place to lead on workforce equality and diversity work but this had been overshadowed by other priorities and not given the importance it deserved.
  • While work had recently started, the trust needed to continue to ensure that medical leaders could be as active and embedded in services as their colleagues in other clinical leadership roles and disciplines. Medical leaders didn’t always have the capacity and the voice in all triumvirate working across the trust. Their workloads had prevented them being an active partner in the triumvirate leadership model.
  • Leaders didn’t have full oversight in several key areas, including of the Mental Health Act. Despite leaders making improvements in the governance data they had access to, this wasn’t always accurate.
  • Leaders didn’t always have access to reliable data and key stakeholders had expressed concerns about this. Inspectors found examples of discrepancies in medical staff vacancy rates and equality, diversity and inclusion data which leaders needed to correct and update.
  • Staff told inspectors there was a disconnect between them and leaders, with signs of a blame culture as well as racism and harassment. Although leaders believed their culture shift to becoming a learning organisation was active, inspectors saw areas where this wasn’t happening consistently in practice. Staff felt leaders communicated poorly which led them to feel untrusted and undervalued.

However:

  • In March 2024, the trust began an organisational change programme which involved leadership changes, a review and reorganisation of lines of accountability, and strengthening of clinical leadership. Inspectors spoke to associate directors, department heads and senior leaders in services who supported and encouraged speaking up. In response to staff survey findings, leaders had taken steps to engage with staff and develop compassionate leaders across the organisation through leadership programmes.
  • The trust had experienced a significant level of scrutiny and had shown openness to the reviews and investigations that have taken place. This period had affected the progress of plans, strategies and stakeholder relationships.
  • Inspectors found strong, robust and effective working in the oversight of safety and quality at the trust. Leaders were skilled, passionate and committed to delivering high quality care by prioritising the safety of the people the trust supported.
  • Leaders were working to build relationships with partner organisations and played an active role in regional collaborative groups.
  • Leaders were aware of the trust’s impact on environmental sustainability and were able to provide examples where they had made changes to reduce the trust’s carbon footprint. These included growing green spaces, improving food menus to reduce waste, and using alternative cleaning products.