Humber Teaching NHS Foundation Trust

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

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

Good: This meant people were safe and protected from avoidable harm.

Both wards were clean. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well. However, improvements were required to ensure the wards met the needs of all people, were well maintained and fit for purpose.

This service scored 72 (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: 3

We scored the service as 3. The evidence showed a good standard. The service had a positive culture of safety. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to identify themes and trends, identify improvements and embed good practice.

The service informed us that they recorded all incidents and accidents on the trust’s online incident reporting system which were monitored at service level. The organisation had governance systems in place, including assurance and auditing processes. Leaders of the service spoke with us about monitoring themes and trends of incidents on a weekly basis, for example, it had been identified that incidents were higher on specific days and times. The multidisciplinary team were examining the reasons and what could be done to mitigate this in terms of individual needs, staffing or additional activities.

We reviewed a team performance report compiled in September 2025 and in the previous 12 months the service had recorded 1870 incidents. On average 84% of these incidents were categorised as ‘no harm’ and an average of 15% of these incidents categorised as ‘low harm’. The service reported 6 incidents, rated ‘medium harm’, 5 on Willow ward and 1 on Lilac ward from December 2024 to November 2025. The service had not recorded any incidents categorised as ‘severe harm’. We also reviewed 70 incidents reported between 01 October to 31 October 2025, 43 on Willow ward and 27 on Lilac ward. The incidents reported included violence and aggression (30%), self-harm (19%) and deliberate damage to the environment (16%). These included incidents of staff being assaulted by people (20%) and a safeguarding incident. All incidents were reviewed by the corporate safety huddle and the actions taken were proportionate and included professional curiosity.

The service used audits to review the number of incidents and any use of restraint, which were also monitored by the trust’s crisis and risk management group and restrictive practice group. The trust had a Use of Force Act policy in place aimed to reduce the use of force and ensure accountability and transparency. The trust complied with the Patient Safety Incident Response Framework (PSIRF) which sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety.

All staff we spoke with told us they knew what incidents to report and how to report them. The service had a development and improvement plan which included issues that staff had raised regarding incidents, post incident support and racial abuse whilst at work. Actions taken included giving staff the opportunity to attend the daily corporate safety huddle, to request 1:1 sessions with a member of leadership to learn about follow-up actions after an incident and establishing an actively anti-racist service through the Culture of Care Programme.

Staff understood the duty of candour. They were open and transparent, and gave people and families a full explanation if and when things went wrong. Families we spoke with confirmed that the service contacted them if an incident had occurred.

Staff we spoke with confirmed that they received feedback from investigation of incidents, both internal and external to the service. The service discussed immediate learning from incidents in handovers and safety huddles and themes and trends as part of team and leadership meetings. Staff we spoke with told us that the ward’s debrief process following an incident and opportunities for reflective practice were good.

There was evidence that changes had been made as a result of feedback, for example the service carried out a thematic analysis of incidents, as a multi-disciplinary team, identified possible trigger points and made positive changes such as occupying time, meaningful activities and zones of regulation (a framework for organising feelings and emotions into four coloured zones) and we observed this in use on the wards.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the person was received to determine if the person’s needs could be safely met. The team told us that they also considered the existing needs of people and the patient mix when considering new referrals into the service.

Townend Court was an acute assessment and treatment unit providing a therapeutic model of care which embedded Positive Behaviour Support (PBS) and trauma- informed care as core principles.

Staff involved all the necessary healthcare and social care services to ensure people had continuity of safe care, both within the service and post-discharge. The service had collaboration with and links to community services to establish community relationships for people with the aim to improve success when discharging them. When considering discharge, the service also considered the person’s voice and wishes and external partners told us, “The team have a strong awareness of the persons risks and continue to offer collaboration to provide a continuity of care.”

We spoke with future care providers as part of the inspection, and they confirmed that the service supported an increase in Section 17 leave to support increased time in the community and support relationship building with support staff. Advocacy informed us that, “Meetings are organised in good time and include all relevant professionals, and communication remains good throughout the transition process.”

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were trained in safeguarding adults and children, and staff were 94% and 99% compliant, respectively. All staff we spoke with could give examples of how to identify risks and protect people from harm; they knew when to escalate concerns and how to make a safeguarding referral. Staff members told us they had good knowledge of safeguarding and were aware of the trusts internal safeguarding team. They knew who the speak up champion was and told us there was a clear escalation process.

Staff knew how to make a safeguarding alert. Between 17 Nov 2024 to 17 Nov 2025, the wards had logged 9 safeguarding of vulnerable adult referrals, this data detailed the reason for the referral and the outcome.

We reviewed the blanket restrictions register for the wards. These included locked doors to the kitchens, laundry rooms and gardens on both wards. The register also tracked time limited restrictions put in place due to risks or safety concerns. During our inspection, we identified some issues with opening the doors to the garden on Lilac Ward. Alternative access to the garden was available through the dining room however, during our ward tour the dining room was also locked on Lilac Ward. This was not a current restriction noted on the register.

Mental Capacity Act

Staff received training in Mental Capacity Act and the Deprivation of Liberty Safeguards and 96% of staff had training in the Mental Capacity Act. The provider had a policy on the Mental Capacity Act, including Deprivation of Liberty Safeguards. Staff were aware of the policy and had access to it.

Staff we spoke with had a good understanding of consent including in relation to the Mental Capacity Act. People were supported to communicate and make decisions to enable the service to deliver person-centred care and treatment in line with people's best interests.

For people who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions.

When people lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.

There were 2 Deprivation of Liberty Safeguards applications made in the last 12 months to protect people without capacity to make decisions about their own care.

Staff audited the application of the Mental Capacity Act and acted on any learning that resulted from it.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to people and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 4 care records and found that all people had up to date risk assessments and risk management plans in place.

The wards focused on the least restrictive practice approach. Records showed the service had recorded 169 restraints in a 12-month period prior to inspection. There were no incidents of prone restraint during this time. All restrictive interventions were reviewed in multi-disciplinary team meetings and analysed monthly through reporting and governance. Records showed that staff completed training on managing conflict, which was 100% compliant and an accredited course on De-escalation Management and Intervention (DMI) and compliance at the time of inspection was 91%.

The service had minimal use of rapid tranquilisation. The wards had reported 2 uses of rapid tranquilisation between November 2024 and November 2025 and the last use in January 2025. The wards reported 12 instances of seclusion in the same time period. The last use of seclusion was in July 2025, and staff used it for the least amount of time possible.

Staff involved people in care planning and risk assessments shown by evidence in care plans and participation in multidisciplinary team reviews. One person we spoke with told us, “I am very involved in creating this.” We were told they had been supported to write parts themselves and they liked to use colours and stickers in the care plan.

Staff communicated with people so that they understood their care and treatment, including finding effective ways to communicate with people with communication difficulties. The speech and language therapy team had developed a meeting book to support communication during reviews and meetings.

Staff enabled people to give feedback on the service they received, for example, via verbal feedback, surveys or monthly community meetings.

Staff ensured that people could access advocacy. We received feedback from the independent advocate who told us, “Staff have always supported advocacy support for my advocacy partners and facilitated this very well.”

Quality Statement Score: 2

We scored the service as 2. The evidence showed some shortfalls.The service did not maintain the environment, and it did not meet all the needs of people. They did not always make sure equipment, facilities and technology supported the delivery of safe care.However, the service did detect and control potential risks in the care environment.

During our inspection and tour of the environment we observed multiple areas which had been damaged and overall maintenance of the environment was poor. The service had a maintenance worker who would make regular repairs to the environment, however, due to regular damage and the higher specification of some of the furniture that required replacing, this was unable to be replaced quickly. The trust evidenced that the necessary fixtures and fittings had been ordered and undertook remedial action to secure safety within the service, such as conducting regular audits.Some staff we spoke with described the environment as, “barren and bland” and felt the environment at Townend Court did not meet the needs of all people. The wards had bright lights, it was noisy and the ward did not have a sensory room to meet individual sensory needs. However, we reviewed a sensory care plan in place for one person using the service, which advised on sensory preferences and activity that would benefitthe person. We were told the wards were purposefully low stimulus to minimise sensory input due to the needs of people, and they were large and spacious which enabled people to have space from each other. There were no working clocks on Lilac ward or an orientation board, on either ward, displaying information. However the trust informed us that people using the service had access to their own mobile phones, tablets, and watches, which enabled them to independently check the digital time at any point throughout the day.

One person was being supported in long term seclusion (LTS). The area did not have a two-way communication system, so we observed staff having to speak through the closed door on multiple occasions. We spoke with relatives during the inspection who told us that when they rang to speak with their relative, this was also facilitated through the door and they told us, “It is difficult to hear and understand what he is asking for.” We asked staff about this, who confirmed it was correct and they showed us a gap in the door frame where they held the phone. We were informed that staff did not take the phone into the LTS area due to known risks.

We saw evidence that staff did regular risk assessments of the ward environment, positioning of staff, supportive engagement and the number of people using the service enabled staff to observe all parts of ward.

At the time of our inspection the wards complied with guidance on eliminating mixed-sex accommodation. Both wards were mixed sex however individual rooms had en-suite facilities and the females on the wards had their own lounge area.

Staff had access to alarms and people had easy access to nurse call systems, however we noted that these were loud within an environment where noise can be challenging for people with learning disabilities and autism. The service could provideear defenders for people using the service and the trust informed us thatthey planned to implementalarms, which had a silent function. There was a planned phased roll out across the trust with a planned start date in March 2026.

The service had a seclusion room which allowed clear observation and two-way communication, it had toilet facilities, an outside space and a visible clock which showed the correct time and date. The service also had a low stimulus / de-escalation area. The clinical lead informed us that the person in LTS sometimes used this space as an extension from the main LTS area as they could lock off the female corridor and enable safe access.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. They were well maintained and there were regular auditing and checks completed as per service guidelines.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The trust had a comprehensive mandatory training programme and the target for training was 85%. The overall compliance at the time of our inspection was 94%. However, training records showed that 3 courses were below this target including Immediate Life Support (ILS), 77%, Mental Health Act, 69% and Clinical Risk, 67%. The service could explain the reasons for this and had plans in place to improve the target.

In addition to the training, we had some concerns that there were not enough staff to carry out physical interventions safely, if required. Some staff we spoke with told us that members of staff from the Intensive Support Team (IST) were not all trained in De-escalation Management and Intervention (DMI). We spoke with the leadership team regarding this. They informed us that the business continuity plan for the inpatient unit was for IST to support when the inpatient unit dropped below their safer staffing numbers. Management ensured the correct amount of DMI trained staff were available to undertake any restraint safely, as per trust policy. We checked rotas for the previous 4 weeks which indicated this was the case during this time.

The hospital used a system which allowed managers and staff to review the skill mix, number of nurses and vacancies for each shift. The service did not have any vacancies at the time of inspection. The service used the Intensive Support Team (IST) to cover for staff sickness, leave, training and increased staffing levels. When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. During the day, we were told the service required 2 nurses to be on shift. The minimum number of support workers on a day shift was 4 and 3 on a night shift, but this was dependent on needs and supportive engagements. However, on the first day of our inspection there was only 1 nurse on shift when we arrived. The ward manager and clinical lead told us they were often part of staffing numbers and external partners also told us that they experienced low staffing levels which impacted on people, such as delayed Section 17 leave. However, the trust informed us that Section 17 leave was monitored through the Mental Health Legislation Steering Group and informed us that there had been no reported cancellation of leave due to staffing and just 1 reported cancellation of leave due to an incident.

People had regular 1-to-1 time with their allocated nurse. There were no recorded instances of staff cancelling escorted leave or ward activities due to staffing levels. However, we were told by staff and external partners that some escorted leave was, “often dependent on whether there was a member of staff who drove and general staffing levels which has fluctuated.”

The trust reported the staff turnover rate (12-month position) was 18% and sickness absence (12-month position) 7%.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency. We spoke with the responsible clinician who told us that there was an on-call rota in place for staff contact and support out of hours.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

All ward areas were clean. We observed housekeeping on the wards during our inspection and no concerns were raised by people, families or external partners who regularly came onto the wards.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date and stickers showed equipment had been calibrated, as required.

Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. The ward had monthly audits in place and followed up on any actions.

Staff adhered to infection control principles, including handwashing.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff followed good practice in medicines management that is, transport, storage, dispensing, administration, medicines reconciliation, recording and disposal and did it in line with national guidance. The service had audits and checks in place, we reviewed records which were maintained daily and these reflected regular auditing and this was overseen by the trust’s pharmacist. Where the service used covert medication, this was care planned and staff consulted with the pharmacy team regarding the ways this could be given. There was good oversight of the wards monitoring by the pharmacy team.

Emergency medicines and equipment was available, accessible and regularly checked.

Staff reviewed the effects of medication on physical health regularly and in line with National Institute for Health and Care Excellence (NICE) guidance, especially when the person was prescribed a high dose of antipsychotic medication and health monitoring maintained. We checked 5 prescription charts and found a low-level use of controlled drugs and PRN medications. We found monitoring of these good and the nurses we spoke with were knowledgeable.

The service applied the STOMP framework (stopping over-medication of people with a learning disability, autism or both) effectively and we spoke with the responsible clinician regarding the reductions, changes to medication and the regular reviews in place in line with NICE guidelines. A relative we spoke with told us, “Medication is prescribed to calm him down…medication was not agreeing with him and that has been stopped. He is so calm and so happy”.