Hampshire and Isle of Wight Healthcare 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.

This is the first inspection for this service since the formation of the new trust. This key question has been rated requires improvement. We found 4 breaches of regulations in relation to waiting list management and the monitoring of people waiting for services, not meeting targets for contacting people within 72 hours of discharge from a ward and the deployment of sufficient staff, including compliance with staff supervision, appraisal and mandatory training and compliance with physical health checks.

Requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service did not always establish and maintain safe systems of care, in which safety was managed or monitored. Systems to monitor safeguarding incidents, referrals and associated actions were not consistent across the service. Not all people had up-to-date risk management or crisis plans. The service did not always deploy sufficient staff, including medical staff. Not all staff completed required mandatory training, nor received regular supervision. Staff did not always complete annual physical health checks for people.

However, safety incidents were reported and investigated thoroughly. Lessons were learnt to continually identify and embed good practice. The service mostly made sure equipment, facilities and technology supported the delivery of safe care. The service mostly assessed and managed the risk of infection. The service mostly ensured that medicines and treatments were safe and met people’s needs, capacities and preferences.

This service scored 44 (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.

Staff described a no-blame culture and regular team meetings to share learning from incidents. We saw learning from incidents was a standing agenda item on team meeting agendas. They told us they were encouraged and supported to raise incidents on the trust online incident reporting system. They told us they received feedback on incidents they reported.

The service provided data that showed there had been 350 incidents across all services between June and August 2025. Of these the largest number of incidents related to self-harm or self-injurious behaviour, with 47 incidents reported. There were 41 incidents reported of assault, abuse or threat to staff, people who used services or the public. The service reported 25 treatment or care related issues.

The service had 22 serious incidents in the last 12 months. There were 6 in the Isle of Wight division, 6 in the Mid and North division, 5 in Portsmouth and South East Hampshire division and 5 in Southampton and South West Hampshire division. In all the reported incidents a person died, of which 8 were suspected suicide.

Managers were supported to investigate incidents by the patient safety leads and quality managers as well as a dedicated trust team. They spoke highly of the support offered by the trust team and said this had improved since the formation of the new trust. Managers supported staff following any serious incidents and organised debriefing for staff. We were given examples of support offered by both psychology staff and the trust critical incident support team.

We reviewed the After Action Reviews (AAR) for 4 incidents. They were comprehensive and included exploration of what was expected against what actually happened. They were led by a senior staff member with all relevant staff included and their voice reflected in the review. They included a description of the person, which also included the views of carers and families. AARs used the Systems Engineering Initiative for Patient Safety (SEIPS) model to identify any system barriers or human factors that may have contributed to the incident. The SEIPS model provides a structured way to understand complex healthcare systems to improve quality and patient safety by analysing the interactions between people, tasks, technology, the environment, and organisational factors.

Service leads attended weekly Patient Safety Incident Response Framework (PSIRF) meetings to look at incidents in their area. 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. They also attended monthly divisional PSIRF learning response meetings to discuss learning from incidents across the trust which was then shared with staff in team meetings. Staff also received weekly bulletins by email which included learning from any incidents.

We reviewed the monthly patient safety matters bulletin shared with staff for July 2025. We saw this contained information about incidents across the trust, key safety messages and learning themes from investigations.

Staff gave examples of learning from incidents in their teams. For example, in 1 team they were working to ensure all people had a carer communication plan in their care record following an incident of harm, where the family had been contacting the team to express concerns. They introduced a red flag on the care record home page to alert staff to the fact a carer communication plan needed to be completed.

The service had no never events in the last 12 months. Never events are defined as wholly preventable patient safety events.

The service provided data showing there were 51 incidents in the last 12 months which required duty of candour to be followed. Duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person. Of these there were 15 incidences where the person using services, carers or family were not contacted. Ten of these had reasons for not contacting the person recorded. Of the 13 incidences where an investigation report had not been shared 10 had reasons for not sending the investigation report recorded. We reviewed an example of a duty of candour letter. We saw it contained a sincere apology and outlined the investigation process. It invited the family and carers to contribute to the investigation and to meet with managers. It also signposted them to further resources such as bereavement care and advocacy services.

Staff received training on being open and duty of candour with compliance varying between 75% and 100% compliance. We saw examples of duty of candour being applied and managers meeting with families following incidents during our inspection.

Leaders reviewed trends and themes from incidents. The quarterly integrated patient safety, safeguarding and learning from deaths report brought together key information on activity related to patient safety, learning from deaths and safeguarding to enable oversight of themes across these areas. The report for April to June 2025 identified 4 areas of concern. There were not enough staff in the clinical safeguarding support team to meet the demand needed to support staff with safeguarding queries and concerns. The trust had recruited further staff to address this. There were a number of incidents awaiting manager review or closure and each division had a recovery plan in place. There were 26 (out of 42) safety improvement actions from patient safety investigations that were open. Each division monitored and reviewed their backlog of open actions. The report stated duty of candour compliance had improved from the previous quarter following the introduction of divisional oversight and additional training offered to staff. The report showed staff compliance with contacting people to enact duty of candour was 86% and compliance with sending investigation reports was 93%. However, in only 50% of duty of candour cases was a letter sent. The trust had carried out training with teams to improve documentation of duty of candour.

The service received 1 prevention of future deaths report in July 2025 related to a death by suicide in November 2023. The coroner found 2 matters of concern related to the service. The coroner told the service it should review training for agency staff, in particular risk assessment training. They also told the service it should review guidelines and procedures for communication with family and friends of people who used services and monitor if communication has taken place. At the time of our inspection the service had not submitted an action plan to address these concerns as it was not due until the end of September 2025.

The trust had a suicide prevention strategy for 2024 to 2025 which was overseen by a suicide prevention group. This included representatives from primary care, public health and community partners as well as senior trust staff. The annual suicide report was reviewed in May 2025 by the trust mortality review group. The report highlighted an increase in reported suicides in 2024 to 2025, with 77 reported compared to 51 in 2023 to 2024. The 2023 to 2024 numbers were based on data from each legacy trust. The report concluded the rise was in line with the national upward trend and possibly related to the increased numbers of people the trust now served.

Leaders from each division attended the monthly trust mortality review group, which heard reports from the monthly divisional mortality review groups. We reviewed the minutes of the last 3 meetings. The trust group reviewed reports and learning from each division and shared a summary of learning. Any deaths were reviewed using a structured judgment review approach (SJR). SJR is a way of learning from deaths of people using health services, even when no specific concerns have been raised. It uses feedback and scores to evaluate care and identify areas for improvement. Managers used a mortality dashboard to track mortality data. The service was developing local dashboards to track the progress of reviews.

The service did not always establish and maintain safe systems of care, in which safety was managed or monitored.

The service did not monitor incidents of harm for people who were waiting for community mental health services. We asked for, but the service was unable to provide, information on the number of safety incidents involving people who were on the waiting list for services. They told us incident reporting systems did not have a specific category for reporting of waiting list incidents, but they would fall into ‘admission/discharge/transfer/referral issues’ category. We looked at incidents for the service for the last 12 months and saw only 2 incidents reported in this category, both in the same team. Therefore, we could not be assured the service had oversight of the risks to people waiting for services and any potential incidents associated with this.

The service did not have a policy or procedure for the management of waiting lists. They told us they used a standard operating procedure (SOP) from a legacy organisation, but this did not apply to services on the Isle of Wight or in Portsmouth. The division with the longest waiting list for allocation to a mental health practitioner was Isle of Wight. We reviewed the SOPs for legacy organisations. The SOP for Portsmouth adult mental health recovery teams did not reference how to manage a waiting list other than for people waiting for dialectical behaviour therapy. The SOP for teams in Southampton and Hampshire stated a ‘RAG rating system’ would be used to manage any waiting lists and if a waiting list happened this would be placed on the divisional risk register. The service did not provide a SOP for services on the Isle of Wight.

We reviewed the draft standard operating procedure for adult community mental health teams (CMHTs) which was not ratified or in use at the time of our inspection. The draft SOP also stated a ‘RAG rating system’ would be used to manage any waiting lists. It did not give detail on the rating system or how often the waiting list would be reviewed. ‘RAG’ stands for red, amber and green and is a system to prioritise and recognise levels of risk.

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 varied between 50% and 100%, with overall compliance across the service at 80%. In Portsmouth and South East Hampshire division compliance was between 66% and 72% across all teams except the EIP team at 89%. In Mid and North division all teams were above 90% compliance. The team with the lowest compliance was West CMHT in Southampton and South West division, at 50%. Follow-up after being discharged from a mental health ward is critical for patient safety, with the highest risk of suicide occurring within the first few days of leaving care. NHS England recommends people receive a follow-up appointment within 72 hours.

The service had shared care agreements with primary care networks across all geographic areas. A shared care agreement is a formal arrangement where an NHS trust specialist initiates treatment and, once the person is stable, transfers responsibility for ongoing prescribing and monitoring to the GP. We reviewed an agreement they had with a primary care network within the Portsmouth and South East Hampshire division. This had not been updated since the merger and contained the name of the previous trust.

The effectiveness of shared care agreements with primary care providers differed across the service. Staff reported difficulties with some GPs agreeing to shared care, whereas in some GP practices there were mental health workers who supported the person’s transition back to primary care.

The service had different approaches to providing assertive outreach to people who required more intensive support. In most CMHTs this was integrated within the shared care or care co-ordination model. However, Southampton had an Assertive Outreach Team (AOT). This included a team leader, nurses, support workers and a consultant psychiatrist. They had an agreed pathway with weekly escalation meeting with social care. The team was awarded a care award in 2024 for their work. We did not see this model duplicated in other teams and divisions and some local managers expressed concern about the ability to provide an effective assertive outreach service within their existing teams without additional resource or funding.

We requested the trust’s policy, process and any audits in relation to the use of Right Care, Right Person. Right Care, Right Person 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 told us they did not have a specific policy but supported the integrated care board (ICB) work in this area. They provided the ICB Right Care, Right Person policy and implementation plan. They did not provide evidence of audits to ensure the policy and plan were followed. The implementation plan focused on 13 areas of work to ensure the ICB worked collaboratively with providers to deliver the National Partnership Agreement: Right Care, Right Person Framework. However, the service had not outlined progress, or implementation plans, for 9 out of the 13 areas.

Not all staff had access to relevant information about people who used services to provide appropriate care and effectively manage risk. During our inspection, carer peer support workers told us they no longer had access to electronic care records. This meant they could not access information on potential risks and safeguarding concerns nor contribute to clinical notes. Following our inspection, the trust confirmed the issue had been considered in line with the trust information governance policy and carer peer support workers had access to carers electronic records with access to patient electronic care record as a third party, if required.

The Portsmouth and South East Hampshire division had an Assessment to Intervention (A2I) team which acted as the entry point to mental health services for people who had a Portsmouth GP. They also provided short-term care and treatment of up to 6 months. However, staff told us some people had been with the service up to 2 years. The trust target for initial assessment was 4 weeks. At the time of our inspection the team was not meeting this target with assessments taking 7 weeks to carry out.

The Isle of Wight division had an Access to Intervention (A2I) team who completed routine (within 28 days), soon (within 1 to 2 weeks) and urgent (within 72 hours) assessments for people referred to secondary mental health services both on the phone and face to face. They also provided brief interventions of up to 6 sessions for people who may not need CMHT input or who were waiting for allocation to a CMHT. At the time of our inspection the team had 13 people waiting for an assessment with the shortest wait being 2 days and the longest 22 days. All people waiting for an assessment within 72 hours had one booked within the timeframe. Staff completed a holistic bio-psycho-social triage and assessment with people. All initial triages took place within 2 hours of referral and compliance with this target was 96% in August 2025.

Staff had access to an up-to-date policy to follow for people that did not attend their appointments. The policy guided staff to hold a multi-professional discussion to make any decision regarding discharge following disengagement or non-attendance and ensure outcomes were documented.

Staff involved necessary healthcare and social care services to ensure people had continuity of safe care, both within the service and post-discharge. We saw evidence of liaison and joint working with crisis and home treatment teams, where appropriate, in care records we reviewed. Staff from crisis resolution home treatment (CRHT) attended CMHT multidisciplinary team meetings.

We saw evidence of good multi-agency working with social care, probation, specialist services and referrals for onward care in care records we reviewed.

The service worked with people to protect the right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They shared concerns quickly and appropriately. However, systems to monitor safeguarding were not consistent and not all staff completed all required safeguarding training.

A trust-wide policy set out the requirements for safeguarding supervision for staff, which was additional to clinical and managerial supervision. It set out clear roles and expectations for both the supervisor and the staff member being supervised. It also set out how safeguarding supervision should be recorded and monitored.

The trust had a safeguarding (family approach) policy. However, this was not up-to-date, as it was due for review in May 2025. The policy referred to relevant legislation and set out staff’s duties and responsibilities in regard to safeguarding adults and children. Following our inspection, the trust told us they had merged the policies of legacy organisations to ensure the policy represented differences across previous trust boundaries until these could be aligned into a single system. The policy, therefore, was reviewed regularly to enable the trust to update it as work progressed.

Systems to monitor safeguarding incidents and referrals and associated actions were not consistent across the service. Not all teams kept a central log of safeguarding referrals made. Some teams told us they recorded safeguarding concerns within care records; others told us they did this in minutes of multidisciplinary team meetings. However, most teams reported any safeguarding referrals or incidents on the online incident reporting system. There was a different process for teams who had historic section 75 agreements with Southampton City Council, with those teams recording safeguarding incidents and referrals on a different electronic system. Section 75 agreements are arrangements for pooling resources and delegating certain NHS and local authority health-related functions to the other.

The service told us the safeguarding section on the online incident reporting system was updated at the beginning of July 2025 to ensure that the concerns identified were being logged in line with statutory requirements. The service told us they were aware that due to how this data was exported from the online incident reporting system and displayed on the safeguarding dashboard, there were inconsistencies. They told us work was ongoing to develop the dashboard to clearly display safeguarding data, including highlighting the difference between the number of concerns identified and those that go on to have a safeguarding referral made.

Trust safeguarding leads attended the safeguarding adults board meetings in each local authority area. However, some staff told us they experienced issues escalating safeguarding concerns through the duty system at some local authorities and they did not always receive feedback on safeguarding concerns. They were not aware of partnership meetings, between local managers and the local authority to address this. Some told us joint meetings at management level had stopped in some areas since the trust merger.

Staff completed training in safeguarding adults levels 1 and 2 with compliance over 75% in all teams, except New Forest East CMHT, where compliance with level 2 training was 70%. However, not all relevant staff had completed level 3 training. Compliance was 67% in Recovery Team North (4 out of 6 staff), 20% in Recovery Team South (1 out of 5 staff), 60% in Portsmouth EIP team (3 out of 5 staff) and 64% in the Assessment to Intervention team (7 out of 11 staff).

Staff completed training in safeguarding children levels 1 and 2 with compliance over 75% in all teams, except New Forest East CMHT, where compliance with level 2 training was 70%. Compliance with level 3 training for relevant staff was above 85%, apart from the Access to Intervention team. However, only 1 member of staff was required to complete level 3 training in that team.

Following our inspection the trust told us level 3 safeguarding training was rolled out across the trust from September 2025, and the course was open for staff to book on.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Staff were supported by safeguarding leads within their areas. We saw evidence of appropriate escalation and follow-up of safeguarding concerns in records we reviewed. Staff gave examples of safeguarding alerts they had raised, for example following an incident of domestic violence.

Staff worked with people to understand risks but they did not always have clear plans to manage risks.

Risk assessments were completed in 46 out of 51 records we reviewed. Where completed, these were comprehensive and evidenced family and carer involvement, where appropriate and with consent. Records showed 32 out of 51 people had appropriate risk management plans in place. However, crisis or safety plans were only present in 26 out of 51 records we reviewed. In some CMHTs we saw examples of people with a history of high-risk behaviours who did not have risk assessments and risk management plans completed. In some records, though risks were outlined in progress notes, these were not reflected in risk management plans.

People who used services were not always aware of being involved in safety plans and risk assessments. Of 40 people we spoke to 11 were not aware of their risk management plan or thought they did not have one and 1 person told us they did not have a crisis management plan.

We reviewed the quality assessment tool outcomes for June 2025 for the service. This showed in 97% of records sampled there was an up-to-date risk formulation. There was evidence of a collaborative approach to risk formulation and safety planning in 86% of care records sampled. However, 3 community mental health teams (CMHT) did not submit audit outcomes.

The service collected data in October to November 2024 for early intervention in psychosis (EIP) teams. This showed 100% of people sampled had a risk assessment and 90% of theses covered all identified risks. There was a risk management plan in place for 87% of the sample and 67% evidenced the involvement of families and carers. One EIP team (South) did not submit data to the audit. The same snapshot audit for CMHTs showed 94% of people in the sample had a risk assessment. For 84% of people in the sample, this covered all identified risks. Eighty-one percent of people in the sample had a risk management plan and 34% evidenced the involvement of families and carers.

The trust had an up-to-date policy for staff to follow on the assessment and management of clinical risk in adult mental health settings. This outlined the approach to regularly assess risk and put in place plans which helped the person to minimise and manage any risks.

Both electronic care record systems in use across the service had risk assessment forms inbuilt, which included risk formulation and plans to manage and mitigate risks.

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

Clinic rooms were clean and well organised, with secure medicines storage. However, temperature checks were not always completed consistently at Gosport CMHT. We also found out of date items in the medical supply cupboard. These were removed by staff immediately.

Premises used by teams were secure and staff using consulting and clinic rooms had access to alarms. In some premises, such as the Andover CMHT base, some consultation rooms had anti-barricade doors, which staff could use if they considered this was a risk. Staff at Andover CMHT raised concerns there was open access to the building, which was in a shopping centre. However, all consulting and clinic rooms were locked and could only be accessed with a staff member.

At Gosport CMHT we found doors into staff only areas which should have been locked, were propped open. This was corrected immediately on site. However, we were told of an incident where staff had let a person into the staff kitchen area and left them alone. There were a number of environmental risks in this area such as knives and boiling water. The service had acted immediately to mitigate the risks and ensure the area was kept secure.

At the Newport CMHT and Access to Intervention team base on the Isle of Wight there was a quieter waiting area for people who may be distressed. Access was controlled by staff and there was a discreet rear entrance which could be used if people were distressed or to protect confidentiality. However, some staff and people using services told us they felt waiting areas and consulting rooms were too clinical and did not create a therapeutic environment.

There was no single estates strategy for the trust which covered 2025 to 2026. There were strategies for 2024 to 2025 for each pre-merger organisation. The service told us the trust strategy was in early stages and not available. They told us senior leaders were working on the adult mental health transformation programme which once agreed, would inform the estates strategy.

The service did not use the same electronic care record across all services. In Portsmouth and South East Hampshire division, 2 different electronic care record systems were in use. Staff told us difficulties in using electronic care records impacted on consistency of record keeping. It also meant it was time consuming and difficult for managers to get relevant performance information.

The service conducted ligature anchor point audits and assessments for all community bases which mitigated risks to people who used services adequately. There was a standard operating procedure for the use of ligature cutters and ligature cutters available in each team base.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. Not all staff completed mandatory training.

Some teams had sickness absence rates which were higher than the trust’s average sickness absence rate. The overall trust sickness absence rate from August 2024 to July 2025 was 5.5%. Sickness absence rates for community teams ranged between 2.2% in Rivers CMHT to 13.2% in the Recovery Team South. Eighteen out of 30 teams had rates higher than the trust rate, of which 5 were higher than 9%. The trust target was to reduce sickness absence to 4.8% by March 2026. Twenty-one teams had sickness absence rates higher than 4.8%.

The turnover rate from CMHTs in August 2025 ranged from 0% in Southampton AOT to 40% in Andover CMHT. Turnover at East Southampton CMHT was 33%. For EIP teams, turnover varied from 0% in west area team to 16% in east area. The turnover for the Assessment to Intervention team in Portsmouth was 23%.

Across all teams there were 38.7 whole time equivalent (WTE) vacancies in August 2025. This was against a staffing establishment of 556.7 staff. The largest number of vacancies were in the Access to Intervention team, with 7.1 WTE vacancies. In Portsmouth and South East Hampshire division, there was a 10% vacancy rate in CMHTs. Leaders told us they used bank staff to address this.

There were 8 shifts which were not filled by agency or bank staff in August 2025, these were all at Andover CMHT. Some staff in other areas told us they were not always able to get bank or agency staff due to financial pressures.

Leaders on the Isle of Wight told us work to attract staff to vacant posts had been successful. However, the history of vacant posts had contributed to the increase in the waiting times for allocation to mental health practitioner. This was around 240 days at the time of our inspection.

During our inspection staff expressed concern about the lack of medical cover and the use of remote consultant doctors in some teams. In Portsmouth and South East Hampshire division they were embedding the use of remote consultants and had a project to look at lessons learnt from this approach so they could share learning across the trust. The service found higher attendance rates for video consultations than face to face and the majority of people chose a video consultation when offered. It had also improved the retention rate for doctors with 100% retention of remote working doctors in a 4-year period. However, staff gave an example of 3 days where responsible clinician cover had only been remote and they were unable to get a responsible clinician to review someone on a Community Treatment Order (CTO). Assessments under the Mental Health Act (MHA) must be conducted face to face. A CTO is a legal order under the MHA that allows a person with a mental health problem to be treated in the community instead of hospital, provided they follow specific conditions (like medicines or appointments).

The service provided establishment but not vacancy details for medical staff. This showed across the service 14.8 WTE medical posts were filled with locum doctors out of a total establishment of 46.8 WTE doctors. Leaders told us this was on the risk register due to the impact on continuity of care but that vacancies were filled by locum doctors. People who used services in the Isle of Wight, expressed concern about lengthy waits for consultant appointments and gave examples of seeing multiple locum consultants and delays in getting prescriptions and medicines due to delays in consultant appointments.

The model for medical staff provision was not consistent across the service. For example, medical staffing for the Portsmouth Assessment to Intervention team was 1.5 WTE consultants and 1 WTE specialist doctor. The Access to Intervention team in Isle of Wight did not have any doctors. The manager met weekly with the consultant for the CMHT to discuss any people where they felt a medical opinion might be helpful, but this was an informal arrangement.

We reviewed the medical vacancy recovery paper submitted to the trust board in September 2025 which provided a summary of actions taken to reduce the number of medical vacancies across the whole trust. This included the expansion of doctors working remotely and work to support long-tern locum doctors to get substantive posts.

The trust had a supervision policy which set out the requirements for clinical and managerial supervision for all staff. The policy aligned with professional practice standards for key roles such as nursing, social work and allied health professions.

Not all staff received clinical supervision. In 11 out of 26 teams, compliance with clinical supervision was below 75% with the lowest compliance at the Assessment to Intervention team and Eastleigh CMHT at 50%. The service did not provide information for compliance with managerial supervision. Some staff told us during our inspection they did not always receive supervision.

Not all staff received an annual appraisal in the last 12 months. In the Assertive Outreach Southampton team only 23% of staff received an appraisal. In Fareham CMHT only 27% of staff had received an appraisal. In 4 other CMHTs, New Forest East, Winchester, East Southampton and North East Isle of Wight appraisal compliance was below 50%. However, 5 teams had appraisal compliance above 90%, Bordon and Petersfield, Andover, Rivers North Basingstoke and Romsey CMHTs and Mid and North EIP. This meant not all staff had the opportunity to discuss their performance and development needs, or career aspirations, with managers.

We requested training and induction policies. The service provided the induction and essential training policy for Solent NHS Trust and the organisational induction policy for Southern Health NHS Foundation Trust. It was not clear which policy took precedence and if these policies had been applied across the new organisation or if a new trust-wide policy was being developed.

The trust had a local induction checklist for all temporary staff to complete before starting work in a team. The checklist included key areas such as a tour of the environment, awareness of policies and procedures, access to information technology and specific duties, roles and responsibilities.

Not all staff completed all required elements of mandatory training. Compliance with Basic Life Support (BLS) Level 1 was 50% in West and Central Isle of Wight CMHT. Compliance with BLS level 2 varied between 44% and 100% in teams, with the lowest at 44% in North East Isle of Wight CMHT. Compliance with BLS and AED training was 55% in the Isle of Wight EIP team and 67% in Recovery Team North. AED stands for Automated External Defibrillator, which is aportable, easy-to-use medical device that can restart a heart in sudden cardiac arrest by delivering an electrical shock. AEDs are found in public places, are crucial for saving lives, and are used alongside cardiopulmonary resuscitation to improve survival rates after a cardiac arrest.

Compliance with assessment and management of suicide risk was below 76%. In Recovery Team North it was 42%, in Recovery Team South it was 56% and in Isle of Wight EIP team it was 64%. In the Assertive Outreach Team Southampton suicide awareness training compliance was 69%. However, most staff completed suicide awareness training, with the lowest compliance in Southampton AOT at 69% and compliance at 100% in 18 teams.

Not all staff completed required learning in working with people with learning disabilities and autistic people. Compliance with level 1 training was above 75% in 9 out of 14 teams. In West and Central CMHT it was 0%, West Southampton CMHT 56%, Central Southampton CMHT 58%, Andover CMHT 60% and New Forest East CMHT 71%. Compliance with level 2 online learning was above 75% in all teams except North East Isle of Wight CMHT which was 67%. However, compliance with level 2 face to face training was low, ranging from 0% in Bordon and Petersfield CMHT to Meadows North Basingstoke CMHT at 78%. Compliance was below 75% in 18 out of 19 teams.

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. However, not all staff had completed infection prevention and control training.

The service had appropriate policies and guidance for staff to follow in relation to preventing and controlling infections. Staff could access guidance on infection prevention and control from the infection prevention and control policy on the intranet.

Clinics, consulting rooms and waiting areas we visited were visibly clean and had suitable furnishings. Staff completed daily cleaning checklists to show premises had been cleaned.

Most staff adhered to infection control principles and washed their hands before giving care and treatment such as injections. However, we observed a depot clinic where both nurses did not wash their hands between people nor before giving an injection.

Staff received level 1 and 2 training in infection prevention and control. However, not all staff completed level 2 training, with the lowest compliance in New Forest East and Eastleigh Southern Parishes CMHTs at 20%, West Southampton CMHT at 22% and west area EIP team at 23%.

The service did not always ensure medicines and treatments were safe and met people’s needs, capacities and preferences. Processes were inconsistent across the service. The quality of care records and documentation varied between locations.

There were systems and processes in place to support people with their medicines. The service made good use of electronic prescription systems (EPS) to meet individual people’s needs and preferences in the community. However, some processes were not followed consistently across all teams and locations. There were examples of good practice (such as the use of recognised side effect rating scales) in some areas, but these were not embedded across the service.

When medicines were being administered by the community teams, consent was usually recorded clearly in the care records. However, consent was not clearly recorded in 6 out of 20 records we reviewed.

Staff supported people with medicines compliance through regular reviews, patient education sessions, and flexible clinic arrangements. Where people were at risk of disengaging, staff used proactive approaches such as unannounced visits, family involvement, and joint working with other services to maintain engagement.

People told us and we saw in records we reviewed physical health monitoring was completed for many people, especially those on high-risk medicines. High-risk medicines are medicines which have known health risks that require additional monitoring or risk management. One person we spoke to said they were “happy that they [the provider] look after my physical health” when attending medicines clinics. When people were overdue for checks, there was a process in place to ensure they were followed up.

However, data provided by the service showed they did not consistently monitor compliance of annual physical health checks for people on long-term antipsychotic medicines. The service was not able to provide compliance figures for the Isle of Wight and Portsmouth and South East Hampshire divisions as the current IT systems did not support business intelligence dashboards to pull this data.

Compliance with physical health checks varied from 100% in Meadows CMHT to 0% in Eastleigh Southern Parishes CMHT. Eight teams had compliance below 75%:

• Fareham CMHT – 65%
• Southampton CMHT – 50%
• Andover CMHT – 44%
• Eastleigh CMHT – 16%
• Central CMHT - 9.5%
• East CMHT - 5%
• West CMHT – 4.5%
• Eastleigh Southern Parishes CMHT – 0%

This meant we could not be assured the service had robust systems to monitor completion of physical health checks for people on long-term anti-psychotic medicines.

In some clinics, such as Gosport CMHT and Isle of Wight central and west CMHT staff used recognised side effect rating scales such as the Glasgow Antipsychotic side effect scale (GASS), but this was not routine in all areas. For example, at Southampton Central CMHT side effects were not always recorded using a standard scale.

Medicines reconciliation was attempted using the Summary Care Record (SCR). The NHS SCR is a national database that holds electronic records of important patient information such as current medication, allergies and details of any previous bad reactions to medicines, created from GP medical records. Some teams had clear processes in place, such as the CMHT at College Keep in Southampton, Other teams, such as Isle of Wight CMHT, relied on verbal handovers or paper records. This meant there was a risk of errors due to inconsistent recording of people’s medicines.

Staff communicated effectively with people’s GPs and other health care providers. However, shared care arrangements were not routinely used across the service. Staff in some locations told us it was difficult to get GPs to take over prescribing. This meant community teams remained responsible for some people who could have been managed in primary care. Use of shared care was inconsistent across the service.

Access to pharmacy support varied across the service. Some CMHTs, such as those in Portsmouth and Southampton, had no dedicated pharmacy input. In contrast, the Isle of Wight CMHT had a dedicated pharmacist who supported different clinics, attended MDTs, and ran ‘patient education sessions’.

Long-acting antipsychotic injections (depots) and clozapine clinics were well managed. Staff in these clinics recorded consent, monitored side effects, and rotated injection sites. Olanzapine depot was administered safely at dedicated clinics. We observed staff complete the required post-dose monitoring and add this to the care record. However, other sites, such as at St. Mary’s in Portsmouth, did not offer olanzapine long-acting injections in a dedicated depot clinic due to lack of facilities for the required 3-hour post dose monitoring. The service told us this could be provided through admission to a pre-booked inpatient day bed for monitoring.

The adult community mental health service carried out some audits on the use of medicines and physical health monitoring. However, this was not routine across all locations. The provider had one bespoke audit they had completed on the use of high-dose antipsychotic (HDAT) medicines in the community recovery teams. This audit showed variable compliance with the national requirements and noted 3 areas for improvement. These were completion and documentation of HDAT form, documentation of discussions with carers and requesting prolactin levels as part of baseline blood investigations. There was an action to address these areas.

Not all staff completed mandatory training in safe use of medicines. Training compliance varied between 100% in 5 teams, to 0% in 3 teams. In Andover and New Forest East CMHTs and Isle of Wight EIP team no eligible staff had completed the required training. In West Southampton CMHT, compliance was 11%, and in Fareham CMHT it was 13%.