Ratings principles: NHS trusts

We follow these principles to determine how we aggregate and combine ratings, and in some circumstances, how we put a limit on ratings.

Reflecting enforcement action in our ratings

Where we are taking enforcement action, we will reflect this in the ratings at the lowest level (key question at individual core service level).

1. Where we have identified a breach of a regulation and we issue a Requirement Notice, the rating linked to the area of the breach will normally be limited to ‘requires improvement’ at best.
2. Where we have identified a breach of a regulation and we take action under our enforcement powers, such as issuing a Warning Notice or imposing a condition of registration, the rating linked to the area of the breach will normally be ‘inadequate’.

Overarching aggregation principles

The following principles apply when we are aggregating ratings.

3. The five key questions are all equally important and should be weighted equally when aggregating.
4. The core services are all equally important and should be weighted equally, except where they are significantly small.
5. All ratings will be treated equally when aggregating unless one of the other principles below applies. Please note: We can adjust the following principles for combinations where it is not appropriate to treat ratings equally.

Aggregating ratings

We use the following principles as the basis of the aggregation and use our professional judgement to apply them to the specific combination of underlying ratings.

6. The aggregated rating will normally be ‘outstanding’ where at least X number of the underlying ratings are ‘outstanding’ and the other underlying ratings are ‘good’.

7. The aggregated rating will normally be limited to ‘requires improvement’ where at least X number of the underlying ratings are ‘requires improvement’.

* Combined trust ratings: Where six trust-level ratings are being aggregated for a combined rating at the trust level (the five key quality question ratings at trust level plus a use of resources rating), the aggregated rating will normally be limited to ‘requires improvement’ where three or more of the underlying ratings are 'requires improvement'.

8. The aggregated rating will normally be limited to ‘requires improvement’ at best where X number of the underlying ratings are ‘inadequate’.
9. The aggregated rating will normally be limited to ‘inadequate’ where at least Y number of the underlying ratings are ‘inadequate’.

Aggregating the overall location or trust levels

We apply additional principles when aggregating to the higher ratings levels (location level and trust level ratings).

10. For each of the key questions of safe, effective, caring, responsive and well-led, the aggregated rating should consist of both:
    • An aggregation of the underlying service ratings
    • An assessment of any relevant hospital or trust level evidence.
11. For foundation trusts only, where NHS Improvement finds a failure to comply with licence conditions or is taking regulatory action, the overall trust rating will normally be limited to ‘requires improvement’ at best.
12. For foundation trusts only, where NHS Improvement puts a trust ‘under investigation’, the overall trust rating will normally not be ‘outstanding’.
13. For non-foundation trusts, where NHS Improvement finds material issues with a trust or where formal action is required, the overall trust rating will normally be limited to ‘requires improvement’ at best.
14. For non-foundation trusts, where NHS Improvement finds concerns requiring investigation, the overall trust rating will normally not be ‘outstanding’.
15. An overall trust rating will not normally be ‘outstanding’ unless its score in the most recent national inpatient survey (question relating to overall experience) is higher than the median for the country.
16. An overall trust rating will not normally be ‘outstanding’ unless, in the most recent NHS Staff Survey, the percentage of staff who would recommend the trust as a place to work or receive treatment is higher than the median for the country.