Hampshire and Isle of Wight Healthcare NHS Foundation Trust

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

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 people’s needs were not always met.

The service did not always ensure people could access a Health Based Place of Safety (HBPoS) when required. The trust often changed the use of the suite which meant it could not be used for its intended purpose and there was a lack of clear policies around this. The trust did not monitor response times for very urgent mental health concerns and the average response time for urgent mental health concerns exceeded the 24 hour target in 4 out of 6 CRHTTs. However, staff made sure people were at the centre of their care and treatment choices, and they understood the diverse health and care needs of people. The service supplied information in formats that were tailored to individual needs and made it easy for people to share feedback.

The service was in breach of regulation for availability of the HBPoS and trust response times for urgent and very urgent mental health care and oversight of this data.

This service scored 57 (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 made sure people were at the centre of their care and treatment choices and they work in partnership with people, to decide how to respond to any relevant changes in people’s needs. However, this was not always documented in people’s care records.

We observed staff providing care and treatment, observed various meetings about people’s care and treatment and reviewed care records for people who used services. Staff ensured people were involved and were able to make decisions about their care and treatment. Although staff were aware of the needs of people who used services, this was not always replicated in the care records we saw. For example, one care record we reviewed named someone as a protective factor, however, that person was no longer in the person’s life.

The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

We observed multiple meetings during the inspection where the care and treatment of people was discussed. Discussions included physical health complications that may impact on whether community or inpatient care was more suitable, family relationships and if they could be used as protective factors to support a person’s care, and whether liaison with substance misuse services would be supportive. Staff demonstrated a good knowledge of each person and their families.

However, discussions also included the delays staff were experiencing when trying to refer people who used services to third party providers.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The service had various policies in place to ensure information governance systems included confidentiality of people who used services. These included a Data Protection and Caldicott Principles Policy, and a Management of Personal Information Policy, which were both due for review in May 2025 but had not been done. The Caldicott Principles are eight standards for handling patient-identifiable information within UK health and social care, ensuring data is used lawfully, securely, and only when necessary.

The service complied with the Accessible Information Standard (AIS). The AIS is a legal requirement for organisations providing NHS care to ensure that people with disabilities or sensory losses receive information and communication support in a way they can access and understand. The trust website met accessibility standards, and information could be easily accessed by making text larger or changing colours and fonts.

Interpretation services were available to support patients with communication needs; this included different languages or signed information for deaf patients. In all the Health Based Places of Safety (HBPoS), staff told us that if information was required in an alternative language to English this could be made available for them. All locations confirmed that when the use of an interpreter was required, this could be arranged. Staff told us that interpreters and translators for British Sign Language (BSL) and other languages could be accessed from contracted providers. Information leaflets could be made available in easy read format or in another language if needed.

Staff told us they talked to people about the importance of taking medicines and offer people who used services information leaflets including different languages. The trust had posters with QR codes for people to access a website that explains medicines in a simple and clear way.

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

We reviewed the complaints at the mental health crisis services and health-based places of safety from October 2024 to August 2025. There had been 1 at Mid and North Crisis Resolution Home Treatment Team (CRHTT), 2 at South West CRHTT, 3 at Southampton CRHTT and none at East CRHTT, IoW CRHTT and the Portsmouth CRHTT. The 2 most recent complaints were in relation to the care being provided at both South West CRHTT and Southampton CRHTT. None of the complaints had gone to the Parliamentary and Health Service Ombudsman (PHSO).

Across all teams there had been 16 compliments submitted about the CRHTT teams from October 2024 to August 2025 with the Southampton CRHTT receiving 14 of those.

The trust had a carers involvement team who shared a carers champions monthly bulletin and hosted regular carers champions meeting. The trust told us about many internal and external service user networks and groups, and also carers and families networks and support groups that people could access such as the families, carers and friends’ involvement group. The service used the Triangle of Care which aims to promote safety and recovery for people with mental health issues and physical health issues whilst supporting their carers.

The trust had a designated feedback team who supported services to gather feedback from people who used services and their carers and families. The trust gave people the opportunity to give feedback on care which included a QR code on various documents such as posters and e-mail signatures for people to access digitally. The trust had a national patient feedback survey for people who had accessed the NHS option 2 service on their website.

The service did not always make sure that people could access the care, support and treatment they needed when they needed it.

The trust had 2 lines for people in the community to call if they needed urgent mental health support. This included NHS 111 option 2, and a crisis line. The crisis line was available 7 days a week from 8 a.m. to 4 p.m. Outside of these times, calls were diverted to NHS 111 option 2 which is a 24 hour, 7 days a week service. Some staff told us they were concerned that there was no link between the location of the call handler with the location of the caller and this could impact negatively. The trust told us callers are routed to the mental health crisis service commissioned in their local area and that occasionally calls may be handled outside their local area due to capacity. For example, a person who required support and lived on the island could be put in touch with someone on the mainland and vice versa. The trust also had a webpage which listed 111 and other third party providers to contact if someone was experiencing a mental health crisis.

In October 2024, the trusts risk register had identified that calls to the Portsmouth CRHTT did not go through consistently for people trying to access services, although no reason was provided for this. The trust had identified that there was a risk that people experiencing a mental health crisis may be unable to access support from the crisis team. This was due to be reviewed in September 2025. Staff at the service told us a new telephone system had been put in but there had been delays and they currently could not access recordings of calls to support learning or follow up on concerns and complaints. Following our inspection, the trust told us that a new telephone system had been implemented on 8 September 2025 and there has been no concerns with calls since its introduction.

We asked the trust for the number of dropped calls to their crisis services in the last 12 months but the trust did not hold this data. We asked the trust for their response times to calls and they told us they were unable to provide this data.

For urgent and emergency community mental health care, very urgent presentations should receive a face-to-face assessment within 4 hours and urgent presentations should receive a face-to-face assessment within 24 hours. We asked the trust for their response times to both and they told us they did not keep the data for the 4 hour assessment response time. The trust provided us with an average response time to meet the 24 hour standard but they did not specify over which time period this average was from. The data showed the average time to respond was:

• East CRHTT – 27 hours
• Mid and North CRHTT – 37 hours
• Southampton CRHTT – 42 hours
• South West CRHTT – 16 hours
• IoW CRHTT – 48 hours
• Portsmouth CRHTT – 18.5 hours

Following inspection, the trust provided us with a Quality Oversight Briefing Paper from November 2025 and an Internal Audit Report from March 2026 which highlighted that since the trust had implemented a new clinical approach the compliance for 24 hour assessments had risen from 30% in April 2025 to 57% in September 2025. The trust also told us that a new dashboard had gone live to capture the very urgent 4 hour assessment data.

The East CRHTT had been added to the trust risk register in July 2025 for not responding to referrals in line with the trusts standard operating procedure or national standards for assessment from GPs, and they recognised the risk of negative patient outcomes because of this. The risk was due to be reviewed in August 2025 which was prior to our inspection.

The crisis team were involved in the MHA assessment process for people detained in the HBPoS wherever possible and would make provision for support in the community if the patient is discharged rather than to an inpatient bed.

We were told and observed the most frequent delay to someone’s care was accessing an inpatient mental health bed. If, after a Mental Health Act (MHA) assessment had been carried out, it was decided to admit the person to hospital, either informally or under the MHA, the bed management team was asked to locate an inpatient bed. If an inpatient bed was not available, in order to avoid breaches of the section 136 24-hour detention period, the assessing Approved Mental Health Practitioner (AMHP) completed a detention application, made out to the hospital in which the Health Based Place of Safety (HBPoS) was located. The individual was then admitted and detained in the HBPoS until a bed on an inpatient ward became available. Across the trust these inpatient beds in the HBPoS were referred to as section 140 beds. Section 140 of the MHA places a duty on local NHS bodies, like ICBs, to notify their local authorities about arrangements for receiving patients in cases of special urgency or for providing accommodation suitable for patients under 18. Therefore, whilst the term ‘section 140 bed’ is a trust-wide recognised phrase, it is not being used by the trust in the defined way by the Mental Health Act.

The LFPSE data showed 10 incidents had been reported from February to July 2025 where people required admission to a mental health inpatient bed but there were no beds available at the trust or the HBPoS was not available due to being used as a section 140 bed. An incident from July 2025 recognised that there was no standard operating procedure in place for the use of section 140 beds.

We raised this with the trust who acknowledged the concerns regarding the increased use of HBPoS as section 140 beds and the impact this could have on flow and availability of HBPoS for Section 136 detentions. The trust had implemented a clinically ready for discharge workstream to improve flow and were working with NHSE and ICB to design a tool for prioritising admissions.

We asked the trust for the longest and average length of time a person is waiting in the community whilst under the care of the CRHTTs whilst waiting for an inpatient mental health bed. The trust provided us with weekly reports for the South East region from 5 August 2025 to 16 September 2025. Of those 5 weeks the HBPoS was not available for 3 weeks for use for section 136 detentions and only available 25% of the time for 1 week and 20% of the time for another week. There had been 84 people waiting admission from both acute and community settings for an inpatient bed with the longest waits from community settings from 2 days to 15 days. There had been 37 people who had been waiting for admission whilst in an acute setting for over 12 hours with the longest wait at 314.4 hours.

Staff and leaders mostly listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this. However, this was not consistent across all services.

The trust had assessed itself against NHS England’s patient and carer race equality framework (PCREF). PCREF is a mandatory framework for trusts to follow to become actively anti-racist organisations by ensuring that they are responsible for co-producing and implementing concrete actions to reduce racial inequalities within their services.

The trust had gathered feedback from the local community through workshops, community events, online sessions, surveys and conversations with professionals, carers and people using services. They had gathered feedback from staff through safe space sessions, engagement sessions, workshops, team meetings and individual conversations. It had an action plan and 8 key recommendations to move the trust towards becoming an anti-racist trust. The people committee monitored the anti-racism programme tracker which showed progress against trust board commitments, anti-racism actions and the communications plan. We reviewed the July 2025 tracker which gave strategic oversight of the actions, deadlines and current progress.

The CRHTT’s all had training compliance in Equality and Diversity between 83% to 100%. However, the data for the staff who supported the HBPoS was not provided.

We asked for and received the ethnicity data for people who used the HBPoS. However, for the Sevenacres HBPoS this information was not available due to the system used to admit people to the HBPoS not having this functionality.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future. However, this was not always documented to ensure continuity of care.

The Southampton CRHTT had regular meetings. We saw multiple examples within the meeting minutes of partnership working to ensure the best outcome for people who used services. This included liaison with the homeless team, police agencies, and charities.

All staff we spoke to told us about the importance of discharge planning from the first point of assessment. They told us the importance of having regular meetings with third party teams such as the CMHTs and GPs to ensure continuity of care but that this sometimes was difficult due to other teams lack of understanding of what crisis services offered. However, staff said discharge plans were not always documented, or if they were, they were difficult to find on either of the care record systems. For example, of the 8 care records we reviewed at South West CRHTT there were no discharge plans but discharge planning was documented as a narrative in the progress notes. Of the 3 care records we reviewed at Southampton CRHTT there was only evidence of discharge planning in 1 care record.