Hampshire and Isle of Wight Healthcare NHS Foundation Trust

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This is the first inspection for this service since the formation of the new trust. This key question has been rated Requires Improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

Care plans were not always up to date. The trust frequently used the HBPoS as a seclusion room contrary to the Mental Health Act. The service did not always ensure appropriate policies were in place. The service did not routinely monitor people’s care and treatment.

However, most people told us that they felt staff cared about their needs and staff told people their rights around consent and respected their rights when delivering care. The service supported people to manage their health and staff shared information across teams and services to support delivery of care and treatment.

The service was in breach of regulation for their use of HBPoS as seclusion suites.

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 did not always make sure care records were up to date and easily available to access information from to support people’s care and treatment. However, most people told us they felt staff cared about their needs and were responsive to them.

We looked at 59 care records for people who used services across the Crisis Resolution Home Treatment Teams (CRHTT) and for people in the Health Based Place of Safety (HBPoS).

Care plans, although completed, were not always kept up to date. For example, one person who used services had a crisis plan and safety plan from April 2023 and progress notes in May 2025 said this had been updated but it had not. There was no dedicated way of working across CRHTTs when it came to documented plans of care. Each service used different care record templates, some used progress notes in place of specific care plans, some people had crisis plans whilst others did not. Physical health and mental health assessments were in some care plans but not documented in others so it was difficult to see what had been completed.

The service provided care as a team and people did not have a designated person to liaise with. This meant that there were times people had to repeat details they had already provided previously to different staff members. Some people said this supported a more rounded view of the care they received. However, some people did say that repeating their information when seeing other staff could be frustrating.

However, most people who used services told us that their needs were always considered. This included discussing a person’s comfort level in different locations and how they would best respond to care and treatment being provided in each. Care was planned based on this feedback and location changed depending on the ongoing feedback each time. Some people also told us that the service were aware of negative triggers and the team would check in with them when they knew a trigger, such as a specific date, was coming up. We also saw evidence that specific training to support people who used services had been provided, such as sensory integration training which had been shared for staff to complete.

In all the HBPoS, people had their physical health monitored closely with their consent. At all locations this formed part of the initial admission process, which included assessment of any risks.

The service did not have continuity of processes, oversight and governance across the health-based places of safety. The service did not follow legislation and current evidence-based good practice and standards.

During inspection, the trust had policies from 3 previous trusts from before the merger which took place in October 2024. However, following inspection, the trust worked with multiple third party organisations to create a Section 136 Multi-Agency Operational Policy.

The trust did not hold their own data on the number of times the Sevenacres HBPoS had been used but they were able to provide us with multi-agency reviews of section 136 episodes. This data showed that Sevenacres HBPoS had been used 119 times from 1 October 2024 to June 2025 and at the time of reporting on 8 August 2025 the suite had been used 17 times from 1 July 2025. The trust told us that the ICB were working on an electronic system to ensure data was accessible to the trust and they expected this to be implemented by 13 April 2026.During this period, Antelope House had 122 instances of the use of the HBPoS. In 21% of cases the section 136 24-hour period was breached. The last occasion of a breach was 10 July 2025. Outcomes of the use of this HBPoS were that 67% were admitted to an inpatient bed. The remaining 33% were discharged back to the community.

Elmleigh had 107 instances of the use of the HBPoS. In 34% of cases the section 136 24-hour period was breached. The last occasion of a breach was 8 July 2025. Outcomes of the use of this HBPoS were that 64% were admitted to an inpatient bed. The remaining 36% were discharged back to the community.

Parklands had 100 instances of use of the HBPoS. In 23% of cases, the section 136 24-hour period was breached. The last occasion of a breach was 24 June 2025. Outcomes of the use of this HBPoS were 41% were admitted to an inpatient bed. The remaining 59% were discharged back to the community.

The Orchards had 137 instances of the use of the HBPoS. In 9% of cases the section 136 24-hour period was breached. The last occasion of a breach was 27 April 2025. Outcomes of the use of this HBPoS were 61% were admitted to an inpatient bed. The remaining 39% were discharged back to the community.

There was a lack of continuity of processes, oversight and governance across all 5 HBPoS locations. Documentation and the recording of information was done differently from site to site. How the HBPoS was staffed varied significantly. There were no regular forums to enable communication between the locations, which could assist with sharing of best practice and learnings from any incidents or concerns raised. We were told by staff that if a patient was transferred from 1 location to another that sharing of clinical records was difficult as they worked with different IT systems. We raised this with the trust who told us they were in the process of standardising place‑of‑safety practices through a new single trust-wide standard operating policy to ensure consistency across all sites which was shared following inspection. The trust also told us that although IT systems differed across sites, there were standardised templates and a trust-wide IT solution in place for a unified approach to section 136 detentions.

Most of the CRHTT teams had low compliance with their mandatory training called “Mental Health and the law".

• East 36%
• Mid and North Hampshire 35%
• Southampton 65%
• South West 36%
• Isle of Wight (IoW) 35%

However, Portsmouth CRHTT had 82% compliance.

The trust used HBPoS as seclusion suites should there be a need from an adjacent ward. The trust had listed on their risk register since June 2024 that the Parklands HBPoS, the Elmleigh HBPoS, and the Antelope House HBPoS had no facility to be able to listen continuously to a patient to ensure their safety when the suites were being used as seclusion rooms. All 5 HBPoS had also been listed on the risk register in March 2025 for not having line of sight observation of toilet or bathroom, no CCTV and no intercom systems when being used as seclusion rooms.

The Mental Health Act states that “Seclusion should only be undertaken in a room or suite of rooms that have been specifically designed and designated for the purposes of seclusion and which serves no other function on the ward.” And that “the room should allow for communication with the patient when the patient is in the room and the door is locked, eg via an intercom” and “rooms should not have blind spots and alternate viewing panels should be available where required.”

The trust had a Seclusion and Long-Term Segregation policy in place that stated, “The Seclusion suites have been specifically designed to ensure that they provide an appropriate physical environment to safely manage patients who may be presenting with increased agitation and aggression.” And “Seclusion must ordinarily only be undertaken in a room or suite of rooms that have been specifically designed and designated for the purposes of seclusion and which serves no other function on the ward.” The policy also stated that the seclusion suite must “…allow for communication with the patient when the patient is in the room and the door is locked,” and have “no blind spots.”

The service did not always ensure appropriate policies were in place and actions appropriately documented to support people. However, we observed staff verbally sharing information across teams and services to support people.

The trust told us that all teams in the mental health crisis and health based places of safety service had regular multidisciplinary meetings. We also observed various meetings which included daily risk meetings and bed management meetings which were attended by team members and also from people working in other relevant teams such as the psychiatric liaison team and the community mental health teams.

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 ICB work in this area. The trust provided us with 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.

Of the 6 care records we reviewed at the Parklands HBPoS, Elmleigh HBPoS and Sevenacres HBPoS, we found that none documented whether the police had consulted with a health professional before section 136 had been used. Following the inspection, the trust told us there is a dedicated line for police to use for advice prior to accessing a HBPoS and that calls are documented on either of the trusts 2 electronic systems.

The trust chaired a regular multi-agency meeting for the HBPoS which included AMHP (Approved Mental Health Practitioner) services, ambulance services, and other external agencies.

Teams had regular meetings where incidents and complaints were discussed, reflected upon, and learning shared. However, the minutes of these meetings were not always taken for staff to review if they had not been able to attend.

The trust used peer support workers across mental health teams including the CRHTT’s, psych liaison, and mental health wards. Peer support workers are people who use their lived experience of mental health problems to support others. The trust told us they had a peer support work group and were developing the model for management of peer support workers.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control.

Some staff told us that due to the nature of the crisis service, supporting people to live healthier lives was achieved through liaison with other services. Some staff told us they could refer people who used services to the community mental health teams who would support the promotion of healthier lifestyles.

We saw evidence of people being referred to teams such as homeless services and drug and alcohol services. Some people who used services told us they felt they were given a choice and had control over their care and treatment.

However, some staff did tell us that physical health and smoking cessation should be a bigger part of their initial assessment.

The service did not routinely monitor people’s care and treatment to continuously improve it.

The trust was implementing a patient rated satisfaction scale to be able to monitor people’s care and treatment. The trust were in the process of training staff on this care planning tool and also supporting the roll out by holding “train the trainer” courses. The trust told us they were creating an eLearning solution with an aim to roll it out by September 2025. Care records we reviewed showed that this tool was not always used consistently. Of 8 care plans we reviewed at the South West CRHTT and Southampton CRHTT where the new tool was available to use, 3 had not been completed. Some staff we spoke to said the new tool, when used, was not always used to review outcomes as it wasn’t always completed at discharge.

Staff told people their rights around consent and respected their rights when delivering care. However, this was not always documented and it was not clear if staff had received appropriate training or were supported by up to date policies.

Each CRHTT linked in with various advocacy services available to people who used services. Staff assumed a person had capacity unless proven otherwise as per the Mental Capacity Act 2005 (MCA) principles and this was mostly documented in people’s care records.

People’s capacity and insight into their care was considered by staff and we saw this documented in most people’s care records and discussed at meetings we observed. Staff told us that they sought consent from people who used services which included consent to share their information with carers and families. We observed consent being discussed at meetings and noted on information boards. Care record systems we reviewed had designated areas to record consent; however, these were only completed in some of the records we reviewed. In some care records, consent was recorded in the progress notes and not in the dedicated section.

Solent NHS Trust audited compliance with the MCA annually before the merger and this had been carried forward to 2024. We reviewed the audit for October to December 2024. The audit looked at 9 records which were for people using psychology services and Talking Therapies and did not include crisis services. There was another audit of MCA and DoLS completed from February to March 2025 but did not state which services were included in the audit and focused on care records that had a DoLS imposed. Following on from the audit findings, the trust advised that their MCA team complete interim spot audits on a quarterly basis to ensure that capacity assessments were being completed.

The trust had an up to date Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS) Policy from May 2024 which stated that all staff must be trained on the MCA however there was no guidance on how compliance will be audited for community mental health services and stated “It is the responsibility of each service line to assure itself it has adequate processes in place to monitor the implementation of the Mental Capacity Act.”

All the records we reviewed across the 5 HBPoS locations evidenced that people had been given an explanation of what detention under section 136 entailed.