Humber Teaching NHS Foundation Trust

On this page

• 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 inspection we rated this key question good. At this inspection the rating has changed to requires improvement. We identified 1 breach of regulation. Patients in the health-based places of safety did not have direct access to outside space or fresh air, and the environment did not promote comfort or provide a therapeutic space.

However, there were enough appropriately trained staff who received regular supervision. Staff assessed and managed risks to people who used services and themselves well. The service managed patient safety incidents well.

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.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The trust had policies and procedures in place and staff knew what incidents to report and how to report them. Managers had access to comprehensive dashboards which provided information for action and analysis. When identified through initial analysis, incidents that met the criteria for further investigation were reviewed in patient safety and clinical assurance meetings using the NHS Patient Safety Incident Response Framework (PSIRF). PSIRF is 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. In the 12 months prior to our inspection there had been no patient safety incident investigations, although the trust had undertaken 54 Initial Incident Reviews, 12 of which were escalated for further review using a Patient Safety Incident Analysis. However, this data was for both the community mental health teams and the crisis resolution home treatment team, so we were unable to determine how many incidents were specific for just the crisis team.

All staff knew what incidents to report and how to report them. They reported all incidents that they should report. Anything that was reported on the trust’s reporting system was discussed the following day in safety huddles.

Staff understood the duty of candour. They were open and transparent and gave people who used services and families a full explanation if and when things went wrong. The trust monitored duty of candour and reported they were 100% compliant from November 2025 to January 2026.

Staff received feedback from investigation of incidents, both internal and external to the service and staff met to discuss that feedback. Any identified themes were discussed in safety huddles, team meetings or reflective sessions. Staff had access to weekly bitesize learning lessons information. Managers told us weekly protected time was used to meet as a team, and they focused on learning lessons and improving the service.

There was evidence that changes had been made as a result of feedback. For example, the multidisciplinary team meeting process had been improved and included the introduction of an at-a-glance RAG rating system and a new proforma which incorporated risk, acuity and family and carer considerations. Previously not all people on the caseload were discussed, only those whose risks were high or where decisions were required about their care. All people on the caseload were now discussed at least once a week, and most people were reviewed more frequently. Another example included a proforma that health care assistants could follow when taking calls on one of the referral lines. This had been introduced following patient safety incidents. The form ensured staff gave appropriate advice and supported clinical discussion with qualified staff regarding decision making.

Staff were debriefed and received support after specific incidents. One staff member who had been involved in a recent incident told us they received a debrief on the same day and supervision was increased to check on their welfare.

The clinical risk management group reviewed people who had died across all services and identified and facilitated any patient safety incident investigations (PSII), patient safety incident analysis (PSIA) and mortality reviews in line with the national Patient Safety Incident Response Framework. This ensured any learning was appropriately identified and disseminated to teams and staff. During the 12 months prior to our inspection, the service had 4 deaths. Managers told us one review identified that staff should ensure they fully involved families and carers in care, however the other 3 found no specific learning points for the team.

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 had a clear criteria of who they offered a service to. The crisis resolution and home treatment teams accepted referrals from anyone aged 18 to 65 years old. The health-based places of safety accepted referrals for people of all ages.

The service’s referral and admission processes ensured that all essential information about the person was received to determine if their needs could safely be met. Staff from either the NHS 111 option 2 service, the mental health triage and assessment team, or the crisis resolution and home treatment team provided an initial screening and triage of all referrals over the telephone to determine whether a full assessment was required. Staff would signpost people to other services if they were not in a crisis, such as third sector organisations. People who had been assessed and referred by another trust team, such as the psychiatric liaison team at the local acute hospital or one of the community mental health teams, would be placed on the caseload with no need for further assessment. This reduced the need for the person to repeat their story.

At the time of our inspection, there were various ways a person could access services. This included the mental health advice and support team, which was not part of the crisis service, NHS 111 option 2, professionals call line and an emergency services call line. The mental health advice and support team was managed by an external provider. The trust planned to amalgamate all call lines to the NHS 111 option 2 service to make it easier for people to access mental health services. The new team would signpost and triage all calls, referring onto the crisis team when required for assessment. The trust was in the process of developing the team and planned to be fully operational by August 2026.

The caseload for the crisis team at the time of our inspection was 21. Staff said this was low and had recently been higher, but several people had been discharged to the community mental health teams following delays while waiting for care coordinators or appointments for transfer of care.

The team had 23 referrals on the first day we were on site. Of those, 2 were for assessment and 21 were for triage, either on the telephone or face to face. Most of the triage referrals were from GPs and staff said the majority would likely be signposted to other services such as primary care, voluntary services or drug and alcohol teams. The team had 41 visits or contacts for the day, which had all been allocated to named staff members.

The service used a team caseload approach and staff could clearly identify people who were at high risk and who required more intensive support through a visual RAG rated zoning system. Visits would be increased quickly or decreased according to people’s individual needs and in conjunction with multidisciplinary reviews and discussions.

Staff reviewed essential safety and risk information about people who used services at least daily in multidisciplinary meetings. These meetings included plans to safely meet people’s needs and discharge planning. We observed 4 meetings and saw robust discussions of people’s risks and staff reviewed care plans, physical health and safeguarding needs for people on the team caseload. Staff demonstrated a good understanding of each person’s risks and planned care and treatment well. Shift coordinators oversaw all tasks, allocated work and provided support and guidance for staff, including those taking referrals.

Staff involved all the necessary healthcare, social care and third sector services to ensure people had continuity of safe care, both within the service and post-discharge. Staff liaised with community teams when people were seen by both community services and crisis teams and involved them in discharge planning. Staff referred to community teams for care coordinators when appropriate and facilitated joint working where they could. The trust and GPs shared the same electronic care note system which meant they could review each other’s notes for admission and discharge purposes.

The trust did not have a standalone ‘Did not attend’ or ‘Non-attendance’ policy. The trust 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. Audits confirmed that staff had not discharged people due to non-engagement and found that discharge related decisions were made through multidisciplinary review and discussion. Staff provided cold calls on the telephone or visited people unannounced at their home if they missed an appointment to ensure they were safe. We saw this reflected in people’s care notes we reviewed.

Staff had developed a frequent caller pathway and discussed frequent callers care plans with other teams such as psychiatric liaison to ensure people were appropriately supported when they made contact through any of the trust routes.

Staff did not always share concerns quickly and appropriately or immediately recognise when safeguarding referrals needed to be made. However, they worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that.

Staff and managers told us they knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Overall, we reviewed 18 care records within the crisis team and the health-based places of safety. We found examples of when safeguarding referrals had been made, and one example of when staff had liaised with police and social services due to safeguarding concerns and historical safeguarding issues were recorded.

However, whilst on site we became aware of 2 people on the crisis team caseload whose safeguarding concerns were not immediately managed. Both people were discussed in the multidisciplinary meeting and despite evident safeguarding concerns being raised, we did not see that any corresponding safeguarding referrals had been made. We raised this at the time of our inspection with the team manager.

Staff completed an incident report when they identified a safeguarding concern. All incident reports were discussed the following day in safety huddles which were attended by a member of the safeguarding team. We observed discussions about safeguarding in the multidisciplinary team meetings and saw actions were agreed.

Staff received training in safeguarding. At the time of our inspection, 95% of staff were compliant with safeguarding adults’ level 1 and 96% were compliant in level 2. For safeguarding children, 100% were compliant in level 1 and 91% were compliant in level 2.

Between 1 December 2025 and 28 February 2026, the team had made 27 contacts to the trust safeguarding team which resulted in 2 referrals to the local authority adult safeguarding team. During the same time period, the team made 7 contacts to safeguard children which resulted in 3 referrals to the local authority.

Safeguarding concerns were monitored in NHS 111 option 2 audits to ensure staff identified and escalated them when required. We reviewed audits from August 2025 to March 2026 and saw any actions had been identified and completed.

In the health-based places of safety, staff only used restraint when necessary and told us it was rare. At the time of our inspection, 100% of staff were compliant with conflict resolution training. Staff in the HBPoS used de-escalation techniques to reduce the need for physical interventions when patients’ behaviours became heightened.

Managers and staff told us there had been a focus on identifying safeguarding concerns and it was discussed in team meetings.

The service worked well with people to understand and manage risks. Staff assessed and managed risks to people who used services and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint only after attempts at de-escalation had failed.

We reviewed 14 risk assessments and risk management plans across the crisis resolution and home treatment teams and 4 from the health-based places of safety. The trust used a structured, person-centred framework to collaboratively understand a person’s difficulties and risks. Risk assessments were completed to a good level, updated regularly and appropriate risk management plans were in place, although we found 1 risk assessment that had not been fully completed. The risk assessments included historical risks. Staff undertook monthly care record audits to ensure risk assessments were completed and updated in line with trust policy. At the time of our inspection, compliance was 97%.

Staff told us they only used restraint as a last resort, and only when de-escalation had failed. From 17 September 2025 to 17 March 2026, there were 12 restraints in the health-based places of safety, one of which was in the prone position facilitated by the police. During the same time period, rapid tranquilisation (RT) was given twice. RT is a medicine used to sedate someone. Records showed post RT physical health checks were attempted but the patients refused, however visual observations were completed. At the time of our inspection, 81% staff were trained in de-escalation, management and intervention training.When required, staff were supported by suitably trained staff from the neighbouring in-patient wards.

Staff told us they involved people who used the service and their family members or carers in care planning and risk assessments. The initial handwritten mental health crisis intervention plan completed at assessment included details of how to contact services when needed or what to do if risk escalated. However, staff did not consistently record whether the person had been offered a copy of their care plan. Managers completed regular audits on care records and shared results with the team and specific individuals when improvements were required.

Staff enabled people who used services and carers to give feedback on the service they received. Staff sent out surveys through text messaging. A QR code was available on the carers information booklet to give easy feedback and the carers lead led on this.

Staff communicated with people who used services, so they understood their care and treatment, including finding effective ways to communicate when people had communication difficulties. Staff ensured people could access advocacy when required.

The trust had developed a Suicide Prevention and Self-Harm Reduction Delivery Plan for 2026 to 2028 which included 6 priorities that teams should follow to prevent and reduce risk for the people that use their services.

The service did not always detect and control potential risks in the health-based places of safety. However, they made sure equipment, facilities and technology supported the delivery of safe care.

The trust had 2 health-based places of safety (HBPoS) suites both based at Miranda House in Hull. The suites did not have direct access to outside space, therefore patients could spend several hours in the suites without being able to access fresh air. Although 1 of the suites had a window, the patient we spoke with said it was positioned too high for them to reach. There were no call-bell systems in the HBPoS. The patient we spoke with told us they had to wave at the CCTV camera to get staff’s attention or knock on the door. The suites did not have clocks, so patients were not able to orient themselves to the correct time. The patient we spoke with said the environment was bland and uninviting. There were no beds or comfortable chairs in the suite, and the patient had slept on an uncomfortable safety pod. We asked the trust to respond to these concerns. They told us they were aware of some of the concerns raised and planned to review the environment with the trust estates department to make improvements where possible. These included, ensuring sleeping arrangements are comfortable and patients are provided with appropriate bedding and blankets. A call bell system or alternative alert system would be reviewed to determine whether one could be installed. The environment would be decorated in a therapeutic way and appropriate sensory adjustments made. Clocks had been installed.

Staff did regular environmental risk assessments and completed ligature audits which had identified potential ligature anchor points. Staff had mitigated the risks adequately. The suites were clean and well-maintained. Accessible resuscitation equipment and emergency drugs were available and staff checked them regularly. The layouts allowed staff to observe all parts of the suite. There was closed-circuit television (CCTV) which allowed staff to observe patient areas.

When the 2 HBPoS were in use and the police had detained a patient on a Section 136, the police could still bring the patient to Miranda House, but this had to be negotiated with staff to ensure it was safe to do so. One of the interview rooms in the reception area could be used until a suite became free. Interagency policy and guidance was in place to support this. The police would stay with the patient, and the patient remained their responsibility until one of the suites was available for transfer and the mental health act assessment could commence. We asked the trust how many times this had occurred in the 12 months prior to our inspection; however, this was only recorded if an incident took place. For example, there had been only 1 time when this occurrence was recorded and that was due to the lack of availability of an Approved Mental Health Professional overnight.

Staff visited most people at home, however they could see people in 1 of the 3 interview rooms at Miranda House. People could be seen on site if they wished or when agreed with staff due to risk. Interview rooms were clean and tidy, with only a fixed couch inside, although they allowed privacy. Waiting areas were clean although they looked like they needed repainting in parts. There was fixed seating, some posters, and were overseen by reception staff.

The trust completed annual fire risk assessments of their buildings. The last assessment was completed in July 2025 which had included actions for Miranda House which had since been addressed.

Staff had easy access to personal alarms in the HBPoS and interview rooms. The suites and interview rooms were on site with other mental health wards, and these staff would provide a quick response whenever the alarm was activated.

Staff carried out personal searches of patients before they entered the health-based places of safety. Any items deemed to be a risk were safely held in storage.

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 team was budgeted for 83.4 whole time equivalent (WTE) staff; qualified nurses were the highest at 31.6, followed by non-qualified clinical staff at 28, 16.8 for administrative staff, 5 for other professional staff and 2 for allied health professionals. At the time of our inspection, there were 12.5 WTE vacancies. These were highest for qualified nurses at 5.6 and lowest at 1 WTE for allied health professionals (such as an occupational therapist).

Managers had calculated the safe staffing number and grade of staff required on each shift. Day shifts required 8 qualified and 6 non-qualified staff, night shifts required 3 qualified and 2 non-qualified staff. These staffing numbers covered the crisis intervention team, the health-based places of safety and the NHS 111 option 2 telephone line. Other staff such as managers and the multi-disciplinary team were available, mostly between Monday to Friday. On the day of our inspection, there were enough staff to manage visits, assessments, triages, the telephones and the HBPoS. There were 19 staff which included student nurses.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. When agency and bank nursing staff were used, those staff received an induction, relevant mandatory training and were familiar with the service. From April 2025 to March 2026, there were 1492 shifts that needed to be covered by bank or agency staff. Of those, 1333 or 89% were successfully filled.

At the time of our inspection, average turnover was nearly 17%. From March 2025 to February 2026, average sickness was 6.6% which was higher than the national NHS average of 5.3%.

There was adequate medical cover day and night. A doctor could attend the HBPoS quickly in an emergency as it was co-located with the in-patient mental health wards. The teams would use the on-call doctor at night when required.

Staff had received and were up to date with appropriate mandatory training. The training was appropriate for the service. At the time of our inspection, overall compliance for all eligible staff and for all training was 83%. Training was lowest for adult basic life support level 2 at 72% and immediate life support level 3 at 73%. Managers told us it was more difficult to get staff booked onto face-to-face training such as life support due to the availability of slots available.

Managers provided new staff with an appropriate induction. New starters would attend a trust wide induction and received a local induction with their supervisor. Newly qualified nurses were provided with a preceptor and supported through the trust’s preceptorship programme.

Managers provided staff with supervision where they met to discuss any operational issues, learning from practice, personal support or professional development. Between May 2025 and February 2026, average compliance for supervision was 85%.

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.

Staff adhered to infection control principles, including handwashing. Staff received training in Infection, Prevention and Control. At the time of our inspection, 92% were compliant with level 1 and 87% were compliant with level 2.

We looked at interview rooms, and the reception and waiting areas at Miranda House. All were visibly clean and tidy, although some areas such the waiting area appeared to require redecoration. Staff maintained physical health equipment well and kept it clean.

The service ensured that medicines were stored safely. They met people’s needs, capacities and preferences and they involved people in planning, including when changes happened.

All medicines used by the team were stored in the HBPoS and were stored safely. The service monitored the temperatures within the medicines cupboard to ensure medicines stored safely. However, the office where staff were based felt cold due to the air conditioning which could make it uncomfortable for staff.

The service had systems and processes in place to safely support people with their medicines in the HBPoS and the crisis resolution home treatment team.

Medicines were stored securely. Emergency medicines such as adrenaline were available. Pre-pack medicines were used appropriately when urgent access to medicines were required. Medicines information leaflets were provided in multiple languages and easy-read formats via the choice and medication website.

Consultant and non-medical prescribers in the crisis resolution team worked collaboratively to support people with their mental health. They had access to pharmacists for clinical queries.

Staff had access to shared care records such as the Yorkshire and Humber care records and national care records service. This supported staff to obtain medicines history and prescribing decisions.

We reviewed the care records for 3 people who were or had been supported by the crisis resolution home treatment team. Risks around medicines and compliance had not been completed for 1 person, however we saw that their medicines had been reviewed and adjustments had been made based on side effects they had experienced. Where the crisis team had identified issues with compliance, processes were in place to provide support with daily administration. This was recorded on paper medicines records, with the quantity supplied recorded on the electronic system.

Processes were in place to initiate and titrate clozapine, which is an antipsychotic medicine requiring additional monitoring in the crisis resolution home treatment team.

Staff attended a daily multidisciplinary meeting where cases were discussed, reviewed and actions put in place to ensure people remained safe with their care and treatment.

Staff had access to equipment to carry out physical health checks and had portable electro-cardiogram (ECG) machines. They encouraged people to have their monitoring completed in line with National Institute for Health and Care Excellence guidance to ensure that treatment remained safe.

The team was engaged with quality improvement projects. For example, they had identified that there was a need to improve the management and review of people who had an ECG and blood tests. A process had been implemented to ensure that requested tests were communicated between health care staff and the medical team.

Data provided to us showed that 87.5% of staff had completed medicines administration training in the last 3 years.