Quality account 2025-2026 (Plain-English)

Frimley Health NHS Foundation Trust provides hospital services and some community services across East Berkshire, parts of Surrey, East Hampshire, Fleet and Farnham. We run these hospitals and sites: 

• Wexham Park Hospital in Slough 
• Frimley Park Hospital in Camberley 
• Heatherwood Hospital in Ascot 
• Heathlands Hospital in Bracknell 
• Farnham Hospital 
• Fleet Hospital 
• St Marks Hospital in Maidenhead 
• King Edward the Seventh Hospital in Windsor 

Throughout the year we used our Electronic Patient Record system, called Epic, to keep patient notes, test results and information about care in one place. This helps teams work safely and share information quickly. 

During the year the Trust made several important changes. We introduced a new structure with four main clinical divisions. Each division is led by a senior team made up of a medical director, a director of nursing, and a director of operations. The four divisions are: Urgent Care and Medicine; Surgery, Theatres, Anaesthetics and Critical Care; Women's, Children and Support Services; and Older People, Neurosciences and Integrated Care. 

We also launched our Trust Strategy for 2025 to 2030. It sets out four goals: highly satisfied patients, engaged staff, modern buildings and equipment, and excellent quality of care. We also published our ten-year Clinical Strategy, which explains how we will provide clinical services in the years ahead. 

We call our approach to improvement Frimley Excellence. It is based on proven methods used in areas where safety and quality are vital. Over the past year we trained more than half of our staff in this approach. In October 2025 we were proud to receive the global Lean Competency System Organisation of the Year award. This recognised our work to build a culture where everyone can help improve quality and safety. 

A pressure injury (sometimes called a pressure ulcer or bed sore) is damage to the skin caused by pressure, usually when someone cannot move easily. Pressure injuries can cause pain and take a long time to heal, so preventing them is very important. 

We aimed to reduce the more serious types of pressure injuries acquired in hospital by 20 per cent, to have zero of the most severe (Category 4) pressure injuries, and to make sure that 85 per cent of patients had a pressure injury risk assessment recorded in their notes with the right care in place. 

We introduced a new national risk assessment tool called PURPOSE-T (which stands for Pressure Ulcer Risk Primary or Secondary Evaluation Tool). This builds on our existing robust approach by helping our teams identify more precisely who may be at risk of pressure injuries and respond quickly with the right care. We successfully introduced this new tool across the Trust and met our 85 per cent target for having proper risk assessments and care plans in place. 

We did not achieve the full 20 per cent reduction in the moderate category of pressure injuries (Category 2), but we did see a 5.6% reduction. This builds on a very large 51% reduction achieved the previous year. Even better, we saw a 69% reduction in the most serious Category 4 pressure injuries, which is a strong sign that we are on our way to eliminating these as is possible. 

The improvements were supported by better training, roadshows for staff, the new dedicated pressure injury team, and a key nursing role focused on preventing these injuries. 

Falls in hospital can cause serious injury, especially for older or frail patients. We aimed to reduce the total number of falls by 20 per cent, reduce the number of falls that led to significant injury by 20 per cent, and make sure 85 per cent of patients had a falls risk assessment and appropriate care in place. 

We did not achieve the full 20 per cent reduction, but we did reduce the total number of falls by 12 per cent, which is the lowest number of falls the Trust has seen in five years. We introduced several important initiatives to help prevent falls, including: 

• A campaign called "Stay in the Bay", which asks a member of staff to stay near patients who are at highest risk, so that they can respond quickly if help is needed. 
• A campaign called "Call Don't Fall", which reminds patients that they should always use their call bell to ask for help, and reassures them that staff are there for them. 
• A "Think Yellow" campaign in our Emergency Departments, where patients at risk of falls are given a yellow blanket, yellow non-slip socks and a yellow wristband. This makes it easy for every member of the team to spot who might need extra support. 

We saw a rise in the number of falls that were classified as causing significant injury. This was not because more people were being seriously hurt, but because we changed the way we classify injuries to match the more rigorous national approach. Being honest and thorough in the way we record incidents helps us learn and improve. 

For the year ahead, we are investing in forty new ultra-low beds with built-in falls monitors and floor lights for night-time, trialling new falls sensors on chairs and toilets, and expanding the Think Yellow initiative to more wards. 

Good nutrition and hydration are essential for recovery. Malnutrition (not getting enough of the right nutrients) is common in people who are unwell or older and can lead to slower recovery and worse health outcomes. Our aims were to identify patients at risk of malnutrition within six hours of admission, provide the right care to address it, introduce protected mealtimes on all adult wards, and make sure 85 per cent of patients said they always got the help they needed at mealtimes. 

We used a tool called the Malnutrition Universal Screening Tool (or MUST) to assess patients. We did not meet the ‘six-hour’ assessment target overall, mainly at our two acute hospitals (Wexham Park and Frimley Park). However, our smaller community hospitals did meet the target. Once patients were assessed, ongoing weekly re-assessments were done well, at 90 per cent or above from July onwards. 

We did successfully introduce protected mealtimes across the Trust, and we met our target for patients saying they got the help they needed at mealtimes. This has made a real difference to people's experience in our hospitals. 

In December 2025 we received a formal notice from the local Coroner, called a Prevention of Future Deaths Notice, relating to nutritional care. This is a notable level of concern. In response we set up a new Nutrition and Hydration Safety Steering Group in January 2026, led by one of our Deputy Chief Nurses. We are extending this priority into a third year to make sure we get it right. 

Plans for the year ahead include an alert system on our Electronic Patient Record system to identify patients who are losing weight unexpectedly, and a prompt review by the wider clinical team when this happens. 

Medicines are used to treat many conditions, but they can cause harm if mistakes are made. We aimed to improve the accuracy of medicines information at every step of a patient's care, from arrival to going home. Two important measures were medicines reconciliation (comparing a patient's home medicines with what is prescribed in hospital, to spot any differences) and safe prescribing of "take-home" medicines when patients leave. 

We did not achieve the pace of improvement we had hoped for. Medicines reconciliation completed within twenty-four hours of admission stayed at around 55 to 65 per cent, which is short of our 85 per cent target. However, we made progress in encouraging staff to report incidents relating to medicines given to patients on discharge, so we can learn from these events. 

A lot of positive groundwork was laid this year. We ran workshops with over 80 frontline staff to map out how medicines information flows through our systems. We updated and published our Medicines Reconciliation Guidance, and we developed a new safe-prescribing licence for every prescriber joining the Trust. Improvements were also made to how nurses complete the discharge process on our Electronic Patient Record. 

Although this will not be a formal quality priority next year, the improvement work will continue through our Medicines Safety Committee and other groups. Our Chief Pharmacist is leading a full review of clinical pharmacy services.

Involving patients and their families in planning a hospital discharge is important for a smoother transition home and better recovery. We aimed for 80 per cent of patients to say that staff had involved them in decisions about leaving hospital, and 80 per cent to say their family or carer had been involved. We also aimed to reduce the average length of stay for people admitted as emergencies to 7.25 days across the whole Trust. 

We did not meet the 80 per cent involvement targets, but we did see small improvements towards the end of the year. In the most recent national Adult Inpatient Survey, we scored above the national average, and the section on leaving hospital placed us among the top 20 per cent of Trusts in the country. 

On length of stay, the Trust average was 7.80 days by year end, above our target. However, four wards taking part in a new Pathway to Discharge Ward Leadership Programme achieved a 16 per cent reduction in length of stay, cutting average stays by around two days per patient. This programme will be expanded to more wards in the coming year. 

Other improvements included a revised Flow and Escalation Protocol, several multi-agency events focused on discharge, a campaign called "PJ (Pyjama) Paralysis" encouraging patients to get up and dressed by 11am each day to speed recovery, and new digital tools to support morning board rounds where the whole team discusses each patient's plan.

A "Never Event" is a very serious patient safety incident that should never happen if the correct safety measures are in place. Even one Never Event is too many. We commissioned an independent external review of Never Events at our Trust, and we are acting on its findings to strengthen the safety of surgery and other invasive procedures across all our sites. 

Given the Coroner's Prevention of Future Deaths Notice received in December 2025, and because our nutritional care work has not yet delivered all the improvements needed, we are continuing this focus into a third year. This priority will now cover both malnutrition and hydration monitoring. 

When a young person with an ongoing health condition moves from children's services to adult services, this can be a difficult time. We want young people to be actively involved in planning their own care and to have a smooth, well-supported experience. Our Governors chose this priority because they have heard from many families that this needs to improve. 

We want to make sure our teams have the training and skills to give safe, kind and understanding care. This includes making sure we know when patients need adjustments to how we deliver care (such as more time, quieter surroundings, or specific communication styles), and that we work closely with people who have lived experience of learning disabilities or autism. We also want more consistent use of Health Passports, which are personal documents describing an individual's needs and preferences. 

National evidence shows that women and birthing people from ethnic minority backgrounds, those living in areas of deprivation, and those with additional needs such as disability or a learning disability often experience worse outcomes. We want to reduce these inequalities in the care we give, so that every woman and family has an equally good experience and equally good outcomes. 

The Care Quality Commission is the independent regulator of health and social care services in England. They inspect our services and give us ratings. During the reporting period, the Care Quality Commission carried out inspections at Frimley Park Hospital and Wexham Park Hospital, focusing on urgent and emergency care and medicine. The results, published during the year, moved Wexham Park Hospital's overall rating to Outstanding, and Frimley Park Hospital's overall rating to Good. Overall, Frimley Health NHS Foundation Trust remains rated as Good. 

We are compliant with the registration requirements of the Care Quality Commission. We continue to meet regularly with our local Care Quality Commission assessors to discuss our services, our improvement work, and any challenges we face. 

When someone dies in our care, we take this very seriously. We have a structured process for reviewing deaths to identify anything we could have done better and to share learning. All deaths that are not investigated by a Coroner are reviewed by independent Medical Examiners, who provide an extra layer of scrutiny. 

We use two national measures of how many patients die in hospital care compared with the number expected, based on how ill patients were when they arrived. Both measures show that our mortality is as expected or lower than expected when compared with other NHS Trusts. Our teams use these measures to look for any specific areas of care that might need attention.

The National Health Service constantly learns from national inquiries. During the year we reviewed several important reports and inquiries and took action where relevant. These included: 

• The final report of the Infected Blood Inquiry. 
• The third report of the Covid-19 Inquiry, which examined the impact of the pandemic on healthcare. 
• The second phase of the David Fuller Inquiry, which looked at how deceased people are cared for in hospital mortuaries. We have acted on nineteen recommendations for NHS Trusts, most of which are now complete. 
• The Thirlwall Inquiry, following the case at the Countess of Chester Hospital. The final report is due after the summer. 
• The Independent Maternity and Neonatal Investigation, launched in June 2025 by the Secretary of State for Health and Social Care. Our Trust is not one of those included in local investigations, but we welcome the review and any national recommendations. 

A blood clot in a deep vein (deep vein thrombosis) or in the lung (pulmonary embolism) is a serious risk for hospital patients. Assessing every patient on admission helps us to prevent these clots.

The national target is for 95% of adult patients to be assessed within fourteen hours of admission.
Our performance this year was around 90%, which is below the national target.

Some of this is due to challenges in how the data is pulled from our computer systems. We are working to improve both the recording of assessments and the reliability of the data. 

We work hard to prevent infections that people can catch while in hospital. Two key infections we monitor are Clostridium difficile (C-diff - a bacterium that can cause serious diarrhoea) and MRSA (a bacterium resistant to many antibiotics). 

The overall number of Clostridium difficile cases at the Trust reduced by 7% this year, though we did exceed the annual limit set for the Trust. Case reviews identified a delay between the onset of symptoms and the collection of samples on the Frimley Park Hospital site, and we have provided extra education and support to address this. 

For MRSA blood infections, we saw a reduction from six cases the previous year to two cases this year, following several improvements including a focused campaign about the safe care of intravenous devices. 

The Friends and Family Test is a simple question asked to patients across the National Health Service: how was your experience of our service? Patients can answer very good, good, neither good nor poor, poor, very poor, or don't know. 

Overall, 93.1% of patients rated their experience as very good or good, and 3.9% rated it as poor or very poor.

Ratings were highest in our community services, inpatient wards, outpatient areas and maternity services (all above 95% very good or good). The Emergency Department scored 78% very good or good, reflecting the pressures on urgent and emergency care.

Common themes in the positive feedback were kind and caring staff, high-quality clinical care, clear communication, and well-organised care. 

Nearly 75% of our staff said in the National Staff Survey that they would be happy for a friend or relative to be treated at our Trust.

This is well above the national average of 60.8%.

The Trust also scored in the top group of hospitals nationally on many other measures, and in the top ten per cent on four of the nine key themes. 

For the seventh year in a row, our maternity services fully met the safety standards of the national Maternity Incentive Scheme.

Staffing levels are important for safety, and we have kept a strong workforce with steady recruitment, low sickness rates (down from 7.5% in 2022 to 3.2% in 2025), and much lower midwife turnover (down from 20.1% in 2019 to 9.1% in 2025). 

We work with four universities and had 149 student midwives on placement across the Trust, helping to secure the future workforce. 

Positive developments included:

• keeping families together in our new born units;
• keeping bereavement services strong;
• improving language and interpretation services;
• introducing sensory boxes for neurodivergent visitors;
• launching midwife-led antenatal education classes in Urdu and Nepali.

A new digital antenatal education platform, provided in partnership with The Real Birth Company, is available in multiple languages and formats to help women and families prepare for birth. 

Our Maternity and Neonatal Voices Partnership actively engages with mothers, families and diverse communities to shape services. Events have included community forums in Slough with interpreters and mental health resources.

We are also working closely with voluntary organisations, community groups and faith leaders to reach people who may otherwise be hard to engage. 

In July 2025 we introduced the Preterm Optimisation Passport, a set of evidence-based steps to give the best possible start to babies born early. Our neonatal service also delivered a project on Delayed Cord Clamping (a practice that helps improve outcomes for new borns), which was recognised nationally as innovative practice. 

MBRRACE-UK is a national research collaboration that reviews deaths of women and babies during and shortly after pregnancy.

In early 2026 we received informal notification that the forthcoming MBRRACE-UK report would identify our Trust as having a higher-than-average rate of neonatal mortality for 2024. We reviewed this carefully with our senior clinicians. 

The important clinical context for Frimley Health Foundation Trust is that we care for a comparatively high number of pregnancies affected by congenital anomalies, where survival beyond birth or early childhood may not be expected.  

When these cases are excluded, our stillbirth rate, our neonatal mortality rate and our overall perinatal mortality rate are all reported as average compared with similar Trusts. Every stillbirth and infant death is reviewed through the national Perinatal Mortality Review Tool, and outcomes are discussed at our obstetric governance meetings and with system partners. 

Getting It Right First Time is a national programme that helps Trusts reduce unnecessary variation in clinical care and improve outcomes. All twenty-four of our specialties have been mapped against Getting It Right First Time checklists.

This year we hosted deep-dive visits in areas including paediatric diabetes, tuberculosis, oral and maxillofacial surgery, vascular surgery, and pancreatic cancer. In every case, positive practice was recognised and specific improvements were identified. 

Recognising early when a patient is becoming more unwell is one of the most important things we do. We use a nationally recognised scoring system called the National Early Warning Score, which helps staff spot patients who need urgent attention. 

We have introduced a national programme called Martha's Rule, which gives patients and families a way to ask for an urgent second opinion if they are worried that a patient is getting worse. This is available in our hospitals through a service called Call 4 Concern. Our Rapid Response Teams also use our Electronic Patient Record system to check patients' scores in real time, so they can support wards remotely and know when to visit in person. 

Sepsis is a life-threatening condition where the body's response to an infection starts to harm its own tissues and organs. Early recognition and treatment save lives. Our target is for 90% of patients to be screened for sepsis, and 90% of those who need it to receive antibiotics within the timeframe recommended by national guidance. 

With the exception of one month, we met or exceeded the 90% target for screening throughout the year. Performance for giving antibiotics within the recommended time was more variable, and we have specific improvement work in place with our clinical sepsis leads and digital teams to strengthen this further. 

Medicines safety is overseen by a Medicines Safety Decision Board, made up of doctors, pharmacists and nurses who track medication incidents and design improvements. The total number of medicines incidents which led to physical harm reduced by 23% this year. 

The most common types of medicines incidents were: controlled drugs (medicines that are strictly regulated); doses that were missed; blood-thinning medicines (called anticoagulants); doses that were wrong; take-home medicines; antibiotics; and insulin (used to treat diabetes). Each of these has a specific improvement plan attached to it. For example, we have introduced special measuring tools on every ward to reduce errors when checking liquid controlled drugs, and we are improving how information is shared between recovery units and wards. 

Every hospital has a Patient Advice and Liaison Service (usually shortened to PALS in the National Health Service). This is a team that helps patients, families and visitors resolve concerns quickly or gives advice about how to make a formal complaint. Making a complaint is always taken seriously and we use complaints to learn and improve. 

This year we saw an increase in the number of formal complaints and Patient Advice and Liaison Service contacts, in part because more patients now know how to raise concerns. Response times to complaints improved despite this rise, which reflects better management in the team. Key themes from complaints have informed several of our next-year improvement priorities, including end-of-life care, moving young people from children's to adult services, hydration and nutrition, shared decision-making and consent, appointments, waiting times, and discharges. 

We have moved our Frimley Park Hospital Patient Advice and Liaison Service to a modern, purpose-built Patient Experience Centre at the front of the hospital, with a private room for patients and families. Complaints training has been provided to a wide range of staff, and we now share complaints information regularly with our Patient Safety and Safeguarding teams so that risks can be spotted early.

Behind everything in this report sits a network of committees and groups that make sure quality and safety are carefully overseen. These include the Quality Assurance Committee, the Care Governance Committee, the Patient Safety Steering Group, and the Council of Governors, which represents patients, the public, staff and partner organisations. 

We take part in the national Data Security and Protection Toolkit, which measures how well we protect patient information. This year we were rated as "approaching standards", with a clear plan of work in place to strengthen our position.