Humber Teaching NHS Foundation Trust

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

At our last assessment we rated this key question outstanding. At this assessment the rating has changed to requires improvement. The service was in breach of the legal regulation relating to person-centred care.

Requires improvement: This meant people’s needs were not always met.

Staff managed beds but due to the current configuration of the environment, there was less bed space and therefore less availability for others with learning disabilities for autism to use the space. People had to stay in hospital when they were well enough to leave. The design, layout, and furnishings of the ward did always support the person’s treatment, privacy and dignity. However, staff supported people with activities outside the service and family relationships. Staff helped people with communication, advocacy and cultural and spiritual support. The service treated concerns and complaints seriously, investigated them and learned lessons.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Quality Statement Score: 1

We scored the service as 1. The evidence showed significant shortfalls. The service did not ensure people’s care plans were consistently followed and where they worked in partnership with people and agreed strategies to deliver person centred care, this was not always achieved successfully.

As part of our inspection, we used the Quality of life tool (used for inspecting specialist services for people with a learning disability and autistic people). The tool looks at how well people's care plans are delivered in practice and how well the physical environment met peoples sensory and physical needs.

Our observations and feedback from the team, relatives and external partners highlighted inconsistencies with the delivery of person-centred care and there were unclear boundaries between staff and people who use the service.

We were told by the staff team that the implementation of approaches and agreed strategies were inconsistently applied, for example we were told communication tools and actions in place for people were not always used and we were told, “the human connection could be lost”.

We found that care plans and positive behaviour support plans, included likes and dislikes and clear strategies to deescalate or manage behaviours but were not always understood or followed by all staff. External partners fed back, “Transitions from the hospital can be challenging…we are keen to get people ready for community discharge but feel as though there is a challenge to this.” External partners told us that they fed these concerns back to the service, when care plans were not followed or independence not promoted. We were told that the leadership team were open to this and arranged meetings to discuss and agree actions, but that this was not always followed through.

However, the service made every effort to ensure people were at the centre of their care and treatment choices and as a multi-disciplinary team they discussed how to respond to any relevant changes in their needs. The service had a range of processes in place to facilitate discussions for staff and raise concerns about the care provided for people such as forums, meetings, supervision andvia the dynamic risk assessment overview (this assessment aids professionals to identify, evaluate, and manage risks as situations develop, ensuring safe and adaptive decision-making).Care plans were detailed and one person we spoke with confirmed that it had been written collaboratively with them.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Staff told us that people had access to education, tutoring and activities within the hospital environment and in the community.

Staff supported people to maintain contact with their families and carers, they accommodated visits and phone calls for carers and family members and the 2 families we spoke with during our assessment confirmed this.

Staff supported people to access their chosen place of worship within the community, the trust had a prayer room on site and a chaplain who could visit the wards if requested.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

During our assessment, staff told us they endeavoured to keep carers, families and commissioners updated about the person’s progress. We spoke with 2 relatives and 2 external partners. External partners told us that communication was positive, that the management team were responsive, emails responded to and meetings arranged. However, one family told us recent communication was poor and gave examples of miscommunication between staff which impacted on the person and lack of information provided regarding a change in medication. Another relative told us the person had moved wards but they had not found about this until their review, at this point information regarding the move was fully explained. The trust explained that lessons had been learnt following miscommunication with relatives and families and this included introducing a dedicated link person within the team.

We noted that Care Quality Commission posters with ratings were displayed. Staff made notifications to external bodies as needed. Information governance systems included confidentiality of patient records. Staff audited records to ensure there were no gaps in record keeping, Mental Health Act documentation or Deprivation of Liberty Safeguards paperwork.

We observed several information posters and leaflets within the hospital. This included information about the service, how to raise complaints, how to give feedback and advocacy details. Feedback from community meetings was displayed. The hospital could provide various forms of information, in different languages if required, larger print and easy read documents. The hospital was also working on a pictorial welcome booklet for new admissions. The trust had also launched a new ‘Connect’ website which was a new way to connect with adult learning disability services. The website provided help, advice and support and there was a QR code on the posters for more information.

We reviewed 5 prescription charts and medicines records and 4 care records and saw medicines information was provided in an easy read format.

Care records showed that regular contact with other professionals involved in peoples’ care was documented so communication was maintained throughout the person’s admission.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

People and their families knew how to complain or raise concerns. People were given the opportunity to provide feedback through a range of different ways such as community meetings, verbally to staff or through an independent advocate. People and their relatives were also invited to their ward rounds and able to express their wishes and needs and provide feedback.

Staff we spoke with knew how to handle complaints appropriately.

As part of the inspection, we requested all formal and informal complaints made in the last 12 months. The service had recorded 1 complaint. This complaint had been partially upheld. No complaints had been referred to the Ombudsman in the last 12 months. This complaint had been investigated, and the outcome and actions had been recorded. One of the actions was to write an apology letter to the person and to share the actions taken to support them.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service made sure that people could access the care, support and treatment they needed when they needed it.

The service had 2 wards, Willow ward and Lilac ward. The wards had 14 single bedrooms, 8 on Willow ward and 6 on Lilac ward with en-suite facilities. At the time of our assessment there were 5 people admitted to the service, 2 people on Willow ward and 3 people on Lilac ward. The male side of Willow ward had been sectioned off to provide a long-term seclusion area for 1 person, and another bedroom had been repurposed into a separate female only lounge. On Lilac ward a bedroom had also been repurposed into a separate female only lounge. The current condition of the wards with the adaptations, design of the wards and individual needs had reduced the number of bedrooms accessible to people, and patient mix and need had to be considered before accepting any admissions into the service. Feedback we received from external partners was that the current ward environment enabled space to facilitate the needs of people with sensory processing and dysregulation but that this meant there was less bed space and therefore less support available for others with learning disabilities or autism to be admitted. However, the trust informed us that over the last 12 months there had been no refused admissions and out of area beds had not been utilised. There had been two admissions to the service in the last 12 months and one person already successfully discharged. The trust shared with us that they had recognised the current environment was no longer suitable for the current patient group due to increasing acuity, limitations with the current physical environment, sensory and other individual needs of people.

In September 2025 the current average length of stay was 1257 days for both wards, compared to the previous year which was 433 days. Managers we spoke with told us there were ongoing challenges regarding delayed discharges and the system’s ability to respond effectively to out-of-hospital care needs.

We saw evidence in care records that staff planned for peoples’ discharge, supported discharge and escalated delays. The trust held regular Multi-Agency Discharge Events (MADE), involving the Integrated Care Board (ICB), local authorities, and third-sector providers. The service was collaborating with these partners to plan and deliver future fit-for-purpose accommodation within the community. Staff ensured people had access to post-discharge care, for example, Section 117 aftercare, intensive support team (this team worked with the person in their own residence, to reduce the need for the use of restrictive practices, inpatient services and out-of-area/residential placements) and future support providers.

We also saw evidence that staff ensured the needs of people with mobility issues were met and made reasonable adjustments for people if required, and they had access to walking aids, shower chairs and an assisted bath. The environment was spacious and with the number of current admissions this afforded a person space.

There was adequate medical cover day and night, a doctor could attend the ward quickly in an emergency and the hospital was within a reasonable travelling distance to the local acute hospital.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Staff within the service and the wider organisation promoted a culture in which the people using the service felt empowered to give their views. The service worked closely with relatives of people to gain their views and the relatives we spoke with confirmed that the leadership team were responsive to them, they were invited to relevant meetings and discharge planning.

The service also worked to reduce inpatient admissions by educating and working with providers and supporting community mental health teams to manage people in the community.

The hospital was working towards meeting the core commitments of the Culture of Care Standards, which as an initiative embeds a culture of collaborative and person-centered decision making and practices to improve experiences and outcomes for people.

Staff were trained in equality, diversity, inclusion and human rights and compliance at the time of our assessment was 96%.

The provider had undertaken equality impact assessments of their policies and procedures to ensure they did not place vulnerable people or people with protected characteristics at a disadvantage.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Staff supported people to make decisions about their care and treatment and their future, and this included holding best interest meetings involving relatives, carers and advocates to ensure the best decisions were made regarding their future. The service developed social stories to help people understand social situations and expectations.

The 4 care records we reviewed showed personalised care plans to account for the person’s needs, wishes and feelings and people we spoke with told us they were involved in creating these. Relatives told us they were involved in discharge planning. One relative told us about visiting properties and giving feedback on these and working with the team to improve skills for independent living.

Staff ensured all relevant healthcare professionals and other relevant bodies are involved in planning the care and treatment of people with complex needs.