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

At our last inspection we rated this key question requires improvement. At this inspection the rating has remained requires improvement. We found 4 breaches of regulations in relation to responding to and mitigating risks to people waiting for care and treatment, assessing risks to people using services, including the completion of risk assessments and risk management plans, deployment of enough staff and medicines management.

Requires improvement: The service did not always establish and maintain safe systems of care, in which safety was managed, monitored and assured. Staff did not consistently assess and manage risks to people well. The service did not always deploy sufficient numbers of suitably qualified and supervised staff. The service did not always have effective systems and processes to safely prescribe, administer, record and store medicines.

However, the service managed safety incidents well and learned from these to improve practice. Staff understood how to protect people from abuse and the service worked well with other agencies to do so. All service buildings were safe, clean, well equipped, well furnished, well maintained and fit for purpose. Systems were in place to control and prevent risks of infection.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety based on openness and honesty, in which concerns about safety were listened to, safety events were investigated and reported thoroughly, and lessons were learned to continually identify and embed good practices.

Staff reported incidents using an online incident reporting tool. Staff we spoke with knew how to report incidents and what type of incidents they should report. Most staff told us they felt confident to report incidents and the trust had a ‘no blame’ culture.

Managers were supported by staff from the patient safety team to investigate incidents. The service told us there had been no incidents that progressed to a patient safety incident investigation (PSII) in the last 12 months. They conducted 31 initial incident reviews (IIR). Of the IIRs conducted, 14 were due to an unexpected death and 2 were due to attempted or suspected suicide. Across crisis services and this service, 12 IIRs progressed to further review using patient safety incident analysis (PSIA). Patient safety incident analysis is a structured way to look at adverse events, errors, or near-misses to understand underlying vulnerabilities and prevent future harm.

We reviewed 2 completed PSIA reports. The service used a ‘swarm huddle’ model to review the care and treatment of people involved in the incident. A swarm huddle is a facilitated discussion on an incident to look at what happened, how it happened and decide what, if anything, needs to be done immediately to improve care. The reports included the person’s or carer’s voice and analysis of areas of good practice as well as key areas of learning. Both reports identified a lack of consistency in care across teams and from care coordinators, which we also found during our inspection.

The service provided evidence that changes had been made as a result of learning from PSIA reports. For example, 1 PSIA identified gaps in dual diagnosis pathways and a lack of collaboration between mental health and substance use services. As a result, the service re-launched joint training of dual diagnosis working. All improvement actions were monitored through the Mental Health Patient Safety and Clinical Assurance meeting.

Managers shared learning from incidents with staff in team meetings, safety huddles, multidisciplinary team meetings and by email. We saw evidence this was discussed in minutes of team meetings we reviewed. Staff gave examples of changes made following learning from incidents, for example the development of a forensic pathway as gaps in communication with the community forensic team were noted in an incident review.

The service had zero never events in the last 12 months. Never events are defined as wholly preventable patient safety events.

The service did not receive any prevention of future deaths reports in the last 12 months. A prevention of future deaths report is a report made by a coroner to relevant authorities to attempt to prevent future deaths from causes identified during an inquest.

The service sent a weekly report to the clinical risk management group (CRMG) outlining any deaths of people using services. The CRMG then identified any deaths that might require further investigation and if appropriate they were discussed at weekly complex case meetings with executive leaders. We reviewed minutes of the CRMG for September 2025 to March 2026 and saw all deaths reported the previous week were discussed and any actions agreed.

The duty of candour is a legal obligation for healthcare providers to be open and honest with people who use services, or their families, when something goes wrong with their care or treatment and causes harm or has the potential to cause harm. The service monitored duty of candour and reported they were 100% compliant from November 2025 to January 2026. The service reported 11 incidents which required duty of candour to be carried out in the last 12 months. Staff understood their role and responsibilities in relation to duty of candour and were able to describe how they had applied this in practice.

However, some staff in some teams told us they did not always have the time to report all incidents they should report. Staff were offered support and debrief following any patient safety incidents.

The service did not always establish and maintain safe systems of care, in which safety was managed, monitored and assured. They did not always ensure continuity of care, including when people moved between different services.

The service reported incidents of harm to people who were waiting for care and treatment. They reported 10 patient safety incidents for people who were on the waiting list for care or treatment between March 2025 and March 2026, of which 2 were deaths and 1 resulted in moderate harm. We found 29 incidents reported to the national Learning from Patient Safety Events (LfPSE) system between April 2025 and March 2026, which included 8 incidents categorised as ‘very concerned’. Following our inspection, we asked senior leaders for an action plan to address these concerns. The service carried out a rapid review of 8 cases to ensure any safety concerns were dealt with and 6 cases had an initial incident review conducted in line with the trust policy for dealing with patient safety incidents.

Not all people using services received regular contact from a clinician. The service sent data showing Hull Community Mental Health Team (CMHT) had 33 people with an open referral to the team who had not had any contact from staff in the last 12 months. There were 2 people in Goole CMHT and none in all other teams. At the time of our inspection, Hull CMHT had 230 people who used services but were waiting reallocation to a care coordinator, and therefore not receiving care and treatment. Staff told us this was mostly due to staff leaving or being on long-term sickness absence. We reviewed incident records for January to March 2026 and found 2 incidents of harm for people waiting reallocation, which were an overdose and a death. We reviewed 3 care records for people waiting over 52 weeks. Of these, 2 people experienced an escalation in symptoms and presentation, using crisis contact but with no planned intervention or contact with the CMHT. In both records we identified safeguarding concerns, the service reviewed the care records for these people and confirmed appropriate action had been taken.

At Hull CMHT staff told us they sent a ‘waiting well’ letter which gave people details of who to contact or other services available if they needed help whilst waiting for care and treatment from the CMHT. We reviewed records for 17 people on the waiting allocation list. Of these, 11 people had not been sent a waiting well letter. A further 3 people had not been sent a waiting well letter as they were referred from internal services. A system to audit compliance with sending of ‘waiting well’ letters was introduced during our inspection.

At Hull CMHT only people on the ‘reallocation to care coordinator’ waiting lists were regularly reviewed by a registered practitioner. In October and November 2025 Hull CMHT implemented ‘Project Assure’, where a clinician reviewed the care records of everyone on the waiting list, including people waiting for initial allocation to a care coordinator. However, there was no system for staff to review people waiting an initial allocation to care coordinator on an ongoing basis. This meant that someone’s risk to themself or others could increase, or their mental health could get worse, without the service knowing and being able to put necessary plans in place to support them. Following our inspection, the service appointed a waiting well coordinator and introduced a new standard operating procedure (SOP) for Hull Integrated CMHT and Primary Care Mental Health Networks. The SOP included processes for checking waiting lists and reviewing people on the waiting list.

We observed an allocation meeting at Hull CMHT. People were discussed following discussion at referral meetings or emails to individual managers requesting a priority referral. There was no system to review and identify priority people from existing waiting lists and bring them to this meeting.

Some staff told us people did not always receive continuity in care when transferring between CMHTs and crisis services. Hull CMHT reported 1 incident between January and March 2026 where a person referred by the crisis team in January 2026 had received no contact from the CMHT at the time of our inspection.

Staff at Hull CMHT told us the system for providing duty cover did not always work effectively to ensure each person who contacted duty received support in a timely manner. They told us that because staff on duty also carried out assessments or visits, emails to duty could build up and not be answered in a timely way. They gave an example of a backlog of 91 emails in 1 week. Duty cover is when practitioners are assigned on a rotational basis to handle urgent, unallocated, or crisis tasks for the day.

The service had a ‘was not brought and no engagement policy’, which outlined staff’s responsibilities when vulnerable adults were not brought to appointments or there was no access to home visits for appointments. They told us that systems and processes for managing people who did not attend were embedded across various operating procedures and policies. They told us they had undertaken audits requested by NHS England in response to the Independent Mental Health Homicide Review in 2024 to ensure staff did not discharge people if they had not attended appointments. At the time of our inspection, the trust was developing guidance on adults who decline treatment and/or disengage with mental health services to supplement existing processes. We reviewed 10 audits of individual care records carried out in July 2025. These showed 8 out of 10 discharges were considered appropriate, with 2 lacking evidence of an assertive approach prior to discharge. Both did not have a review from a doctor before discharge. For one person, no discharge summary was recorded in the person’s records and for the other person, the discharge summary lacked detail.

Some staff told us they had positive working relationships with Approved Mental Health Practitioners (AMHP) and gave examples of how they had worked with AMHPs and colleagues from the crisis team to support people in the community and avoid hospital admission. However, other staff told us it could be difficult to access AMHPs for Mental Health Act assessments and gave examples of when assessments had been reprioritised, leaving them managing any risks to the person and others in the community. The service told us staff should complete an online incident form if AMHPs changed an assessment and a review of incident reports between November 2025 and March 2026 showed no reported incidents of cancelled assessments.

We requested the trust’s policy, process and any audits in relation to the use of Right Care, Right Person (RCRP). RCRP is an agreement between policing, health and other relevant partners that sets out the principles around the Right Care, Right Person approach which aims to ensure that individuals in mental health crisis are seen by the right professional. The service provided the joint agency protocol for the partnership delivery of mental health support across Humberside. This included the RCRP principles as partnership delivery of the Mental Health Act and Mental Capacity Act across Humberside and included statutory and voluntary sector agencies involved in this. The service did not provide any audits in relation to use of RCRP. The service told us if there was an issue an online incident report was submitted, reviewed and escalated to the joint interface meetings held with the local police force and ambulance service. This was also monitored through the Crisis Care Concordat.

At Hull CMHT staff and clinicians met twice weekly to discuss all queries sent by local GPs to the team, for example queries about medicines or if a referral to secondary services would be appropriate. They provided advice to the GPs via email, including signposting to alternative services.

In the Psychosis Service for People in Hull and East Riding (PSYPHER), early intervention in psychosis team staff attended care programme approach (CPA) meetings for people who were currently inpatients to start discharge planning as early as possible. They ensured everyone discharged from hospital had a review with a doctor within 4 weeks of being discharged.

The service provided data on the number of people discharged from an inpatient ward who received a follow up contact within 72 hours. The data showed compliance with follow up contact within 72 hours in February 2026 was 97% against a trust target of 80%.

The service worked with people to understand what being safe meant to them as well as with partners on the best way to achieve this. 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, and made sure they shared concerns quickly and appropriately.

Staff were guided by trust-wide policies on safeguarding adults and children, which were available on the trust intranet. The policies outlined the steps staff should take to safeguard adults and children and were current and regularly reviewed.

Staff told us they were well supported by trust safeguarding colleagues to raise any concerns. They gave examples of situations where they had raised safeguarding concerns appropriately. We saw safeguarding concerns were discussed in multidisciplinary team and allocation meetings we observed.

Senior leaders attended safeguarding partnership boards in Hull and East Riding local authority areas as well as key multiagency safeguarding meetings. The trust safeguarding team supported safeguarding reviews alongside relevant staff from the service and offered debriefing and support to staff involved in these.

The service provided information showing 58 safeguarding contacts regarding adults were made with local authority duty safeguarding teams between December 2025 and February 2026, which resulted in 4 referrals. The highest number of contacts (18) were regarding self-neglect. Staff had made 10 contacts with local authorities regarding safeguarding children in the same period.

Staff completed safeguarding training. Compliance with level 1 safeguarding adults training was 100% and with level 2 it was 94%. For safeguarding children level 1 training compliance was 100% and 95% for level 2.

Staff completed Prevent training. Prevent is a UK government initiative aimed at stopping people becoming terrorists or supporting extremist ideologies by offering early intervention and community support. Compliance with Prevent training was 96%.

The service did not work consistently with people to understand and manage risks by thinking holistically so that care meets their needs in a way that was safe and supportive and enabled them to do the things that matter to them.

Staff used a Functional Analysis of Care Environments (FACE) assessment to assess risk and identify a management plan. The trust policy on clinical risk assessment, management and training stated everyone using services should ‘have a safety plan or a risk management plan that is regularly reviewed by the multi-disciplinary team at key points in the service user’s treatment journey and at times of significant change’. However, audits of people’s care records for March 2025 to March 2026 showed staff in Hull Community Mental Health Team (CMHT) did not always complete a FACE assessment, with 46% of records audited having an up-to-date FACE assessment. This was 70% at Holderness CMHT and over 83% in all other CMHTs. Compliance in the Psychosis Service for People in Hull and East Riding (PSYPHER) team was 75%.

Though care record audits for March 2025 to March 2026 showed clinicians made reference in their notes to the presence of potential risks, we found this was not always reflected in risk assessments and risk management plans. For example, we reviewed a person’s record who was subject to Ministry of Justice restrictions, and this was not reflected in their risk management plan.

During our inspection, we found gaps in risk assessments and risk management or crisis plans in care records we reviewed. In 8 out of 15 records reviewed though risk assessments were present they were not up-to-date. In 6 out of 15 records there was no risk management plan and in 10 there was no crisis management plan. There was limited evidence that people were involved in their risk assessment or contributed to their risk management plan, due to gaps in records or limited information in risk assessment and risk management plans we reviewed. However, we did find positive examples of risk assessments and risk management plans in the PSYPHER team and Beverley CMHT, which were detailed and person-centred.

However, people who used services told us staff involved them in assessing risks and putting risk management and crisis plans in place.

Staff completed clinical risk assessment training. Compliance in March 2026 was:

• Beverley, Bridlington and Driffield and Haltemprice Community Mental Health Teams (CMHT) 100%
• Goole CMHT 88.9%
• Holderness CMHT 87%
• Mental Health Triage and Assessment Team 100%
• Psychosis Service for People in Hull and East Riding (PSYPHER), early intervention in psychosis team 89%
• In Hull CMHT compliance was 88% for clinical staff and 100% for non-clinical and psychology staff

Leaders told us clinical risk assessment training included working with people and their carers and using formulation rather than a set risk stratification system. They acknowledged improvements were needed in recording of risk on the electronic care records system and told us they planned to introduce risk assessment refresher training for staff. They told us work was ongoing to ensure staff used risk formulation using the 5 Ps method (presenting problem, predisposing, precipitating, perpetuating and protective factors) in teams. In teams we visited, staff told us though a ‘traffic light’ scoring system was used to identify levels of risk for discussion in safety huddles and multidisciplinary team (MDT) meetings, they used a wide range of information including current and historical risks and a risk formulation approach in MDTs. Risk formulation is a clinical process which looks at someone’s personality, history, mental state, environment, potential causes and protective factors, or changes in any of these. It takes into account that risk constantly changes and looks at factors likely to increase the risk of dangerousness and those likely to mitigate harm to self or violence, as well as signs that indicate increasing risk.

Leaders told us all risks were discussed at a referral meeting to discuss the appropriateness of people going onto a waiting list. The frequency of referral meetings varied across the different teams. Decisions from referral meetings were then taken to allocation meetings between managers and clinicians where key risks were discussed.

The trust had a suicide prevention and self-harm reduction strategic plan for 2026 to 2028. It outlined 6 priorities which were strengthening crisis and post-discharge support, establishing clear treatment protocols, improving long-term engagement, providing tailored support to priority groups, promoting online safety and responsible media content and reviewing suicide data annually and learning from it. Office for National Statistics data showed Hull had a higher rate of suicide than the England average. The plan included an examination of local factors contributing to this. It was overseen by the trust Quality and Patient Safety Group.

The service mostly detected and controlled potential risks in the care environment and made sure that the equipment, facilities and technology supported the delivery of safe care.

The service did not provide ligature risk assessments and audits. Ligature anchor points are any fixed object that could be used to tie something around for the purpose of self-harm, including hanging and strangulation. Following our inspection, the trust provided further information stating ligature risk assessments and audits were not required within trust policy for community mental health team bases. This was because the trust ligature anchor point tool was specifically for inpatient mental health, learning disability and crisis facilities where people who used services may be left without direct supervision. They told us risks within community services were managed through individual clinical risk assessment, staff supervision arrangements, appropriate room allocation, environmental health and safety processes, and escalation to more intensive services where someone’s presentation indicated an increased level of risk.

Premises we visited were secure, with CCTV and staffed reception areas. Clinic rooms were fully equipped and staff could access emergency resuscitation and anaphylactic equipment and medicines if needed.

At Bridlington and Driffield Community Mental Health Team (CMHT) staff completed risk assessments for any specific groups or people using the building. For example, managers had completed a risk assessment for the gardening group which included uneven surfaces, gardening equipment and personal protective equipment. They had completed a guide dog risk assessment as the building was used by a person with a visual impairment.

The service completed annual fire risk assessments for all premises used by community mental health services. These identified any areas which were not compliant with fire regulations and the service acted to remedy these.

Safety managers carried out regular health and safety inspections of the environment. These were shared with local managers and actions to remedy any areas of concern agreed.

Managers carried out regular security risk assessments of premises used by community mental health services. These included key aspects of building security such as keys, identity badges, personal alarms, digital locks and security of the physical environment.

The trust had an estates strategy for 2022 to 2027. This covered capital development, sustainability, estates rationalisation and estates operations. It had 7 goals which included providing environments where staff and people feel safe and which actively promote recovery and providing modern comfortable environments which staff were happy to work in.

The service did not always make sure there were enough qualified, skilled and experienced people, who received effective support, supervision and development and worked together effectively to provide safe care that met people’s individual needs.

In March 2026 the service had 19.11 whole time equivalent (WTE) vacancies across all teams and roles, against an establishment of 173.59 WTE roles. Hull Community Mental Health Team (CMHT) had the highest number of vacancies at 13.49 WTE clinical vacancies, of which 6.63 WTE were nursing vacancies, with an additional 4.19 WTE non clinical vacancies. This was against an establishment of 37.71 WTE clinical roles and 23.94 non clinical roles. However, during our inspection managers at Hull CMHT told us they had recruited 5 nurses who were waiting to start and managers were able to access bank staff to cover gaps in shifts.

Some teams had high sickness absence rates. Between March 2025 and February 2026, the sickness absence rate in Bridlington and Driffield CMHT was 10.4%, in Holderness CMHT 9.4% and in the Mental Health Triage and Assessment (MHTAT), 10.9%. In Hull CMHT, the sickness absence rate was 17.3% for clinical staff and 14% for non clinical and psychology staff.

Some teams had high staff turnover rates. In Bridlington and Driffield CMHT turnover between March 2025 and February 2026 was 19.8% in Goole CMHT it was 17%. MHTAT had a turnover rate of 27.5%. Hull CMHT had a turnover rate of 11.9% for non clinical and psychology staff and 32% for clinical staff.

Staff told us staffing shortfalls were felt across most teams as bank and agency staff were not always used to cover sickness absence. However, data provided by the service showed, from January to March 2026, only 2 available bank shifts were not filled out of 25 available shifts in Hull CMHT.

Staff and managers told us staffing pressures due to vacancies and sickness absence had contributed to the waiting lists within Hull CMHT, including people who were waiting for reallocation to a care coordinator as their usual care coordinator was not available. Staff in Hull CMHT had worked overtime at weekends to review and contact people on waiting lists.

The service had not completed any capacity and demand or staffing establishment reviews in the last 12 months.

The service provided caseload data which showed team caseloads as 289 in Beverley CMHT, 369 in Bridlington and Driffield CMHT, 253 in Goole CMHT, 283 in Holderness CMHT, 188 in Haltemprice CMHT and 432 in Hull CMHT. Most individual care coordinator caseloads were 35 or below with the exception of 1 care coordinator in Hull CMHT at 45 and 1 in Haltemprice CMHT at 39. The service told us the increased caseload was due to group work activity carried out by these staff. The service had produced a caseload allocation framework and allocation rules guidance document for Hull CMHT in February 2026. We requested the caseload management policy or standard operating procedures for the whole service, but they did not provide this. The service told us the standard operating procedure for each team outlined the management of caseloads. Therefore, it was not clear if the same process and guidance applied across all teams in the service.

The overall caseload for the Psychosis Service for People in Hull and East Riding (PSYPHER), early intervention in psychosis team was 284, with individual care coordinator caseloads between 6 and 19. The NHS England recommended workforce tool developed by Health Education England recommends care coordinators in early intervention in psychosis teams have a maximum caseload of 15.

Managers used bank or agency staff, where possible. The trust had an up-to-date bank and agency worker policy and procedure which gave guidance to managers on the processes to follow when they needed to engage temporary, short-term workers. Bank staff received a ‘Welcome to Humber’ booklet when joining the bank which gave them information from key contacts and booking shifts to training and supervision requirements and health and wellbeing. The mandatory training requirements for bank staff were set out on the trust intranet.

However, some substantive staff told us they had not received a local induction when starting work in their current team.

The trust had an up-to-date policy on learning and staff development which outlined the statutory and mandatory training requirements for staff. Most staff completed mandatory training. Data provided by the service showed compliance across all CMHTs in all topics was above 73%, the trust did not tell us their compliance target. The lowest compliance at 73% was for disengagement training and compliance was 100% in fire safety, moving and handling level 2 and level 3 resuscitation training.

The service assessed and managed the risk of infection, detected and controlled the risk of it spreading and shared any concerns with appropriate agencies promptly.

Premises we visited were visibly clean and well-maintained. Staff had access to appropriate personal protective equipment to enable them to carry out their roles safely.

The service carried out quarterly audits of infection prevention and control (IPC) measures in premises used by community mental health services. Audits completed between March 2025 and March 2026 showed 94% compliance with IPC standards.

The trust had an up-to-date IPC policy which set out the duties and responsibilities of all staff and IPC link practitioners. Staff could access support from IPC champions within their teams.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We found that although physical heath monitoring was completed, processes were not always effective in ensuring that any abnormal results were promptly reviewed.

The service did not have effective processes to ensure risks related to medicines and physical health checks were escalated in a timely manner. This meant there was a risk people who used services continued their treatment without a safe and timely clinical review, posing a potential risk to their physical health.

We reviewed the records for 3 people prescribed clozapine who did not receive a review by medical staff within the expected timeframe following an abnormal electrocardiogram (ECG) result to check for rare but sometimes serious cardiac (heart) side effects. We also reviewed records for someone who had not had a medical review with a doctor at the time of our inspection, though they had been monitored at monthly clinics to receive their medicine.

Following our inspection, we told leaders the service should make improvements to ensure risks related to high-risk medicines and physical health checks were escalated and acted upon in a timely manner. The service took immediate action including reviewing cases where escalation of abnormal physical health findings had been delayed, and further developing an improvement programme aimed at strengthening communication and oversight of physical health monitoring across the multidisciplinary team. For example, physical health monitoring templates were developed in the electronic patient records system in November 2025 and the service was refining these electronic templates and engaging with staff to improve consistency of use. This aimed to capture information to support the safe prescribing and monitoring of medicines including clozapine, lithium and valproate, which required additional monitoring.

People reported inconsistent experiences with support and help with medicines. Whilst some people told us they had regular medicines reviews and physical health checks, this was not everyone’s experience. For example, one person told us they had not received physical health monitoring despite being on a lot of medicines. We saw in care records we reviewed community mental health teams (CMHT) worked collaboratively with local GPs to support safe prescribing. However, staff told us that the strength of these relationships varied between teams. The service completed a local audit of physical health monitoring in Hull CMHT, in January 2026. The audit showed compliance with carrying out people’s annual treatment reviews was 84.1%. However, compliance with physical health monitoring was lower, with blood tests at 60.2% and ECGs at 56.8%. Some staff at Hull East CMHT told us that following this local audit, they were looking to strengthen arrangements to help ensure that requests for blood tests and ECGs sent to GPs were completed and followed up.

We saw that clinic letters were sent to people’s GPs following appointments with consultant psychiatrists and processes were in place to identify and follow-up people who missed depot injection appointments. Some staff in the Holderness CMHT told us they worked with staff in local care homes to provide advice and education, to support the care of residents known to the CMHT and on clozapine.

Staff had access to the National Care Records Service to review information to support prescribing decisions. All CMHTs had access to dedicated specialist pharmacist support for clinical advice and queries. The trust pharmacy team provided an onsite medicines audit and stock management service to the CMHTs. They provided specialist pharmacy support for clinical advice and queries to the Psychosis Service for People in Hull and East Riding (PSYPHER), early intervention in psychosis team.