Hampshire and Isle of Wight Healthcare 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 is the first inspection for this service since the formation of the new trust. This key question has been rated 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.

We were not assured that safeguarding concerns were appropriately raised and recorded. Patients who used the HBPoS at the Orchards and Elmeigh did not always have direct access to fresh air. There was not always enough staff who received appropriate training, supervision and appraisal to ensure safe care and treatment could be provided. Systems to support the safe use of medicines were not consistently followed, and oversight of medicines-related risks varied across locations.

However, the service had a proactive approach to safety and they investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. All locations we visited were clean and tidy.

The service was in breach of regulation for safeguarding governance, lack of direct access to fresh air in the HBPoS, lack of staffing, low compliance and lack of oversight of mandatory training and supervision and recording and oversight of medicines.

This service scored 47 (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 a Patient Safety Incident Response Framework policy (PSIRF). This policy supported the requirements of the PSIRF and set out the trust’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents and issues for the purpose of learning and improving patient safety. The trust used the LFPSE (Learn from Patient Safety Events) which is a national NHS system for recording and analysing patient safety events. The Crisis Resolution Home Treatment Teams (CRHTT) had 11 serious incidents in the last 12 months with the most being recorded at East CRHTT with 8. We reviewed the After Action Reviews (AAR) for 4 incidents that had occurred in October and November 2024. 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. Views of carers and families were also included. 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.

The trust told us that Integrated Care Boards (ICB) and Local Authority (LA) representatives were invited to attend any learning response decision meetings and the regular Quality Oversight Group meeting to discuss new and in progress Patient Safety Incident Investigations (PSII).

For all AARs we reviewed, the Duty of Candour had been followed. The Duty of Candour is a legal and ethical obligation for health and social care providers in the UK to be open, honest, and transparent with service users when things go wrong. Staff we spoke to could describe the Duty of Candour and give examples of when this would be used. They were open and transparent and gave patients and families a full explanation if and when things went wrong.

Staff we spoke to were aware of what incidents to report, how to report and the need to learn and make any changes following incidents. Most staff could provide examples where changes had happened due to learning from incidents, such as implementing daily multidisciplinary (MDT) meetings to review risk. We saw on incident reports, and staff told us, that they received debriefs after incidents to ensure wellbeing and support any learning. However, some staff did feel the investigation process had created a blame culture and they did not always feel informed about specific incidents that had occurred.

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. Staff had knowledge of the strategy and training compliance for the CRHTTs was between 84% and 100%.

There had been no Never Events at the mental health crisis services and health-based places of safety within the past 12 months. Never Events are defined as wholly preventable patient safety events.

There had been no prevention of future deaths investigations at the mental health crisis services and health-based places of safety within the past 12 months. Following an inquest or investigation into a death, a coroner may issue a Regulation 28 Prevent Future Deaths (PFD) report to a person, organisation, local authority, government department or agency, where the coroner believes that action to address some of the identified concerns should be taken to prevent future deaths.

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 did not always ensure governance processes were in place to establish and maintain safe systems of care. However, staff worked well to support people who used services.

We requested the trusts referral criteria for people accessing crisis services. The trust provided us with a Standard Operational Procedure for the Home Treatment Team from September 2023 under the Isle of Wight NHS trust and The Adult Mental Health Crisis Resolution Home Treatment Team Standard Operating Procedure from January 2022 under Southern Health NHS Foundation Trust which was due to be reviewed in April 2025 but had not been. We also received a referral process document which had no date or trust name included so we were unclear if this was a recent process or from prior to the trust merger.

The CRHTT’s had shared caseloads and most staff said this worked well. Staff across services told us that referrals had gone up which had directly impacted on their work load. They told us that lack of inpatient beds, barriers to moving people on to CMHTs and inappropriate referrals had negatively impacted on their ability to meet need. However, they also told us that there had been a new process which had just been implemented and regular meetings with CMHTs to support people’s movement through pathways.

Most people who used services said they were frequently seen by different staff from the service, but this did not negatively impact on their care, with some saying it supported a more rounded view of the care they received.

Some members of staff told us that the trust was under Business Continuity Plan (BCP) Black and/or OPEL 4 (Operations Pressure Escalation Levels) due to inpatient bed pressures the trust were experiencing and that the concerns had also been added to the risk register. This risk had been added to the register in August 2023 and was listed as a high risk for people’s care pathway being delayed. The trust had implemented a daily engagement meeting and other avenues to enable discussion and action of mitigation of any risks.

From April 2025 to August 2025 there had been 41 incidents recorded at Elmleigh Hospital HBPoS, 38 incidents at Antelope Hospital HBPoS, 16 incidents at Sevenacres HBPoS, 25 incidents at the Orchards HBPoS, and 53 incidents at Parklands Hospital HBPoS. These ranged from low harm to moderate harm. Moderate harm requires significant, though not permanent, additional treatment or extends hospital stays. Of the incidents, moderate harm was recorded on 1 incident at Antelope House HBPoS and 3 at Parklands Hospital HBPoS. These consisted of the HBPoS being used for long term segregation due to a shortage of inpatient beds, the HBPoS being used for seclusion and a doctor not being contacted in line with seclusion policy, and missing medicines.

The trust had an up to date “Disengagement / Did Not Attend / Was Not Brought Policy” in place. Staff were able to tell us the process to follow when people who used services were no longer engaging with their care and treatment and provided examples where the policy had been followed to good effect. However, the trust did not complete any audits of this process.

The service did not always work well with people and healthcare partners to ensure safeguarding concerns were raised quickly and appropriately. Governance of safeguarding processes were not effective.

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. Most of the CRHTTs had achieved compliance between 78% and 100% on the mandatory safeguarding training data sent to us for both adults and children. This covered safeguarding for both adults and children training in levels 1, 2 and 3 at CRHTT Portsmouth and safeguarding both adults and children training in levels 1 and 2 at CRHTT East, CRHTT South West, and CRHTT Southampton. However, the Isle of Wight (IoW) CRHTT and CRHTT Mid and North did not provide training details for safeguarding adults or children at level 1. The trust told us that safeguarding adults and safeguarding children level 3 training was only required from September 2025 so some compliance levels were not available or low at the time of inspection.

At Portsmouth CRHTT some staff said they were concerned that not all safeguarding referrals were being completed when needed. Whilst on inspection at East CRHTT we observed a safeguarding for a child had not been raised and we raised this to leadership to complete. Some staff at East CRHTT said they were not confident all safeguarding concerns were being raised when needed and provided examples of times safeguarding referrals had not been completed previously. During our review of care records, we found that safeguarding referrals and alerts were not easily accessible for review, or the information had not been recorded. However, staff we spoke to could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff knew how to identify adults and children at risk of, or suffering, significant harm.

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.

The trust told us that between June and August 2025 there had been no Section 42 enquiries relating to the care provided by the Southampton CRHTT, South West CRHTT, Mid and North CRHTT, East CRHTT or IoW CRHTT. There had been 3 section 42 enquiries at Portsmouth CRHTT. Southampton CRHTT had found discrepancies within their data which did not correlate with the incident reporting system and the trust told us they would be supporting training on this.

The trust told us that safeguarding activity from the HBPoS is usually reported via the inpatient ward that is attached to the suite and is unable to provide data specifically for the HBPoS without the inpatient ward data being included. Exceptions to this are when the section 136 24 hour rule is breached or when the HBPoS is not available.

The CRHTTs attended safeguarding board meetings on a quarterly basis covering all 4 local authority areas, and staff had access to a safeguarding advice line for any questions or concerns they had.

The service did not always ensure staff had access to appropriate systems and processes to help people to understand and manage risks. They did not always ensure risk information was easily accessible and available.

The trust told us that they had 2 care record systems in place, and Portsmouth and IoW based teams used one type of risk assessment whilst the other regions used a different one. The trust had an Assessment and Management of Clinical Risk policy which focused on risk assessment, risk formulation and risk management and gave specific timelines of when staff should look at and consider the current risk assessment. These included new admissions, escalation of risk, and discharge from a mental health team. The policy also stated that all staff undertaking risk assessments and management plans are trained. However, the trusts board meeting in August 2025 highlighted that training for staff in assessment and formulation was not available across all of the organisation. As an interim measure the trust had provided CRHTTs with a shortened training offer. Following the inspection, the trust told us they would continue to deliver Clinical Risk Formulation and Safety Planning Training to role specific colleagues from April 2026.

The trust completed an audit of their CRHTTs from October to November 2024. However, there was no data shared for East CRHTT. The audit reviewed 29 risk assessments across the remaining CRHTTs and found that 86% of those had a risk assessment in place, with 92% of risk assessments covering all historical and current risks. Staff told us that risks were reviewed at every visit and this was evidenced in the care records we reviewed. On our review of care records, we found that the system in both the IoW CRHTT and Portsmouth CRHTT were hard to navigate and that risks were not always in one place for easy view.

We saw evidence that people had been involved in their care planning. Consent was sought by staff and this was mostly recorded. People who used services and their families and carer’s opinion were documented in care records using their own words.

In the HBPoS, patients were searched by the police and, where utilised, a third party contracted provider, prior to arrival at the HBPoS. Staff at both The Orchards HBPoS and Parklands HBPoS also carried out their own searches immediately on admission to the HBPoS. Prohibited items were stored in patient lockers.

We asked the trust for the data for patients who had experienced restrictive practice in the HBPoS. From March 2025 to August 2025 there had been 13 incidents that had led to a patient being restrained or secluded or both. Elmleigh HBPoS had no incidents of seclusion or restraint being recorded.

The service did not always detect and control potential risks in the care environment. They did not always make sure that equipment, facilities and technology supported the delivery of safe care.

We asked the trust for their environmental risk assessments for all of the CRHTTs and HBPoS locations. The trust ligature risk audits for all of the HBPoS had all been completed within the year prior to inspection. However, of the 9 locations the CRHTT’s use, we only received 4 ligature risk assessments. One location did not have a ligature risk assessment provided and 4 were for the HBPoS which were located in the same building. Following inspection, the trust told us that the trust policy for completing ligature risk assessments for community patient facing services was every 3 years but we did not receive this policy. The trust also told us that all people who used services when at the service location were directly supervised which mitigated any risk.

During our observations of rooms used to speak to people who used services at both South West CRHTT and Mid and North CRHTT we saw there were environmental risks such as fixed ligature points and no observation windows in doors and no alarms in rooms for staff to use if needed. Some staff at Mid and North CRHTT told us that they did not always have access to personal alarms.

At the HBPoS at The Orchards at St James Hospital there was no access to bathing facilities within the suite. Access to bathing facilities would require staff escorting the patient using the suite to bathing facilities on an inpatient ward. The trust advised us that the suite was due to have a shower fitted in February 2026.

At the HBPoS at The Orchards at St James hospital and at Elmleigh there was no direct access to an outside area or fresh air which was not in line with the Mental Health Act Code Of Practice. The trust told us they would conduct a review of the Elmleigh and The Orchards HBPoS to explore if the arrangements for direct access to fresh air were adequate.

The trust had listed on their risk register from January 2024 that the courtyard for the section HBPoS at Parklands hospital had a low roof next to the garden which would be easily accessible for anyone detained in the section 136 suite. The trust risk register noted that a brief induction for trust staff and the third party provider staff had been put in place to mitigate the environmental risk and allow the use of the courtyard. The next review of the risk was due in October 2025.

The trust used 2 separate care record systems due to the trust merger in October 2024. One of the care record systems had been moved from one system to another prior to the merger and some staff told us they found the new system hard to use. On our review of care records at the IoW CRHTT and Portsmouth CRHTT we found the care record system to be hard to navigate and key information was not easily accessible. Whilst the care records at East CRHTT, South West CRHTT, Mid and North CRHTT and Southampton CRHTT which used a different care record system was easier to navigate.

The trust told us that they were currently in the process of drafting an estates strategy since the merger and this would be shared with staff once agreed.

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

The trust provided us with the last 6 months of turnover data from April 2025 to August 2025. Turnover was the highest in the East CRHTT at an average of 14.8%, the Isle of Wight Home Treatment team at an average of 11.4% and Mid and North Hampshire CRHTT at an average of 10.8%. The trust told us they did not have a target turnover rate.

On review of LFPSE incidents from March to August 2025, there were 4 incidents reported of short staffing in the crisis team, the reports stated that this had caused delays in visits, patient calls and assessments.

Staff at IoW CRHTT reported an increase in caseloads causing delays in assessments. They reported additional challenges due to staff sickness and recruitment difficulties due to their location on the Isle of Wight. Staff also reported delays in handing patient care over to other teams, and a lack of medical cover. Following inspection, the trust told us that a staff grade doctor had since been appointed.

The vacancy rate for band 6 practitioners within the Mid and North Hampshire CRHTT in August 2025 was 34.3% and had reduced since it had originally been put on the trusts risk register in September 2021 from 57%. Staff reported that staffing had been difficult. They also reported no psychology cover, which had impacted both on patient care and staff supervision. Some staff reported feeling unsafe when they were short staffed. This had also been affected by sickness and difficulties recruiting to outstanding vacancies. The service had 6 vacancies out to advert at the time of inspection.

The trust vacancy data showed there was 25.16 (12.8%) full time equivalent vacancies across all crisis services in August 2025. The data did not include staffing for the HBPoS. The East CRHTT had a vacancy rate of 5.73 (13.3%), the IoW CRHTT had a vacancy rate of 4.85 (17.8%), and the Mid and North CRHTT had a vacancy rate of 8.7 (25.9%) with the most vacancies for band 6 nurses across all services. The trust told us they had a 20% threshold for vacancies. The CRHTT teams used both bank and agency staff when required with 551 shifts covered by bank staff and 280 shifts covered by agency staff in July and August 2025. There had been 8 shifts unfilled in July 2025. Across the Hampshire, Southampton and Isle of Wight regions some staff reported that it could be difficult to get a doctor for both assessment for detention and allocating a responsible clinician for patients in the HBPoS. We raised this with the trust who told us that responsible clinician allocation would be based on clinical need, expertise, and service configuration, with any site‑specific variations clearly defined in a protocol to ensure transparency. The trust also said that responsible clinician details would be accurately recorded, understood by HBPoS staff through clear escalation routes, and further clarified via governance processes, including arrangements for minors. However, there was no response to how the trust would know this had been achieved or when they hoped to achieve this by.

We asked the trust for their induction policy. The trust provided us with two induction policies. An induction and essential training policy from June 2023 for the Solent NHS Trust and an organisational induction policy from November 2022 for Southern Health NHS Foundation Trust. There was no induction policy for the trust since the merger in October 2024. Some staff across the CRHTT’s told us that the induction could be improved. However, we did see examples of induction checklists for both permanent and temporary staff.

The trust told us the HBPoS were staffed by the staff on adjoining inpatient wards alongside a third party provider in some contracted situations. Clinical supervision for the staff on the ward had the following compliance:

• Antelope House - Hamtum Ward 73%
• Elmleigh 69%
• Parklands Hospital - Hazel Ward 63%
• St Marys Hospital (Sevenacres) - Seagrove Ward 39%
• St James Hospital (The Orchards) - Maples 55%

The below 5 CRHTTs had the following clinical supervision compliance:

• East 38%
• Mid and North 46%
• Southampton 73%
• West 48%
• IoW 23%

We were not sent the supervision compliance data for the Portsmouth CRHTT. Following inspection, the trust told us that the clinical supervision for the Portsmouth CRHTT was 84%. Some staff told us at CRHTT IoW, CRHTT East, and CRHTT Portsmouth that they did not routinely receive supervision. The trust policy stated that there must be 2 separate types of supervision: clinical and managerial. However, we only received supervision data for clinical supervision.

Staffing of the HBPoS was shared with the adjoining wards, and the training for Immediate Life Support was low with 33% compliance at Sevenacres for Seagrove ward and 69% at Antelope House for Hamtun ward.

We reviewed LFPSE data for staffing on the adjoining inpatient wards and between March and August 2025 and there were 11 incidents of short staffing on wards due to staff being moved to staff the HBPoS. This had also been raised at the trust’s board meeting in August 2025, stating “This is having a significant impact on staffing as the wards require to release staff to support with the place of safety which often results in requests to temporary staffing to facilitate this need, or backfill on the ward, which can be a challenge as they are often not aware of them in advance.”

Training compliance was low across the CRHTTs. Following our inspection the trust updated their mandatory training requirements. On review of the data against the new mandatory training requirements, we found the following had low compliance:

CRHTT East:

• Infection Prevention Control Level 2 33%
• Mental Health and The Law 36%
• Mandatory training for learning disabilities and autism Tier 1 (non-clinical) 67%
• Mandatory training for learning disabilities and autism Tier 2 - Seminar 17%
• Resuscitation Level 2 (Basic Life Support) 70%

And no data was provided for:

• Moving Handling Level 2 – Adult
• Resuscitation Level 1 (Non-Clinical)
• Resuscitation Level 3 (Immediate Life Support) – Adult

CRHTT Mid and North:

• Infection Prevention Control Level 2 46%
• Mental Health and The Law 35%
• Mandatory training for learning disabilities and autism Tier 2 - Seminar 16%
• Resuscitation Level 2 (Basic Life Support) 54%

And no data was provided for:

• Moving Handling Level 2 – Adult
• Mandatory training for learning disabilities and autism Tier 1 (non-clinical)
• Preventing Radicalisation Level 1 (Basic Awareness)
• Resuscitation Level 1 (Non-Clinical)
• Resuscitation Level 3 (Immediate Life Support) – Adult
• Infection Prevention Control Level 1
• Safeguarding Adults Level 1
• Safeguarding Children Level 1

CRHTT Southampton

• Infection Prevention Control Level 2 71%
• Mental Health and The Law 65%
• Mandatory training for learning disabilities and autism Tier 2 - Seminar 32%

And no data was provided for:

• Moving Handling Level 2 – Adult
• Resuscitation Level 1 (Non-Clinical)
• Resuscitation Level 3 (Immediate Life Support) – Adult

CRHTT South West

• Infection Prevention Control Level 2 50%
• Mental Health and The Law 36%
• Mandatory training for learning disabilities and autism Tier 2 – Seminar 13%
• Resuscitation Level 2 (Basic Life Support) 52%

And no data was provided for:

• Moving Handling Level 2 – Adult
• Resuscitation Level 1 (Non-Clinical)
• Resuscitation Level 3 (Immediate Life Support) – Adult

CRHTT Portsmouth

• Mandatory training for learning disabilities and autism Tier 1 (non-clinical) 0%

And no data was provided for:

• Conflict Resolution
• Moving Handling Level 2 – Adult
• Preventing Radicalisation Level 1 (Basic Awareness)
• Resuscitation Level 1 (Non-Clinical)
• Resuscitation Level 2 (Basic Life Support)
• Resuscitation Level 3 (Immediate Life Support) – Adult

Mandatory training for learning disabilities and autism Tier 2 compliance was provided at 95% but does not specify if this was level 2 eLearning or level 2 seminar as in the other data sets.

CRHTT IoW

• Infection Prevention Control Level 2 70%
• Mental Health and The Law 35%
• Moving Handling Level 2 – Adult 5%
• Resuscitation Level 2 (Basic Life Support) 43%

And no data was provided for:

• Infection Prevention Control Level 1
• Moving Handling Level 1
• Mandatory training for learning disabilities and autism Tier 1 (non-clinical)
• Mandatory training for learning disabilities and autism Tier 2 - Seminar
• Preventing Radicalisation Level 1 (Basic Awareness)
• Resuscitation Level 1 (Non-Clinical)
• Resuscitation Level 3 (Immediate Life Support) – Adult
• Safeguarding Adults Level 1
• Safeguarding Children Level 1

The trust told us there were no audits completed for training or supervision.

The HBPoS were staffed by the staff on adjoining inpatient wards alongside a third party provider in some contracted situations. We asked for the appraisal rates for all staff who provided care and treatment under the mental health crisis and health based places of safety but the appraisal rates for the HBPoS staff were not provided.

The 6 CRHTTs had the following appraisal compliance:

• CRHTT East 42%
• CRHTT Mid and North 33%
• CRHTT Southampton 72%
• CRHTT Portsmouth 38%
• CRHTT IoW 27%

The data for CRHTT South West appraisal compliance varied between 71% or 67% depending on the evidence provided by the trust.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading.

The trust had an infection prevention and control (IPC) policy in place. All locations we visited were clean and tidy and staff told us IPC audits were completed. All the HBPoS were clean and smelled fresh. We observed cleaners on site during our inspection. The trust website had various guidance on infection control including the importance of hand hygiene.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Medicines were not always available in a timely manner. Records were unclear regarding when people had been administered or supported with their medicines, and inconsistent pharmacy support impacted the quality of care provided to people.

There were systems in place to support the safe use of medicines, but these were not consistently followed across crisis teams and health-based places of safety. Documentation was often fragmented, and oversight of medicines-related risks varied between locations.

In several crisis teams, medicines records were held across multiple systems and formats, including handwritten notes, prescription forms, and in-house charts. There were variations between teams when recording medicines administration. Some teams used charts whilst others relied on journal entries in electronic records. This made it difficult to establish a clear and accurate picture of what had been prescribed or administered.

Recognised monitoring scales such as NEWS2 (national early warning scale for physical health) and GASS (the Glasgow antipsychotic side-effect rating scale) were used in HBPoS settings. Pharmacy support was not embedded or consistent across all locations. Some teams had no dedicated pharmacy input, while others had temporary support through pilot schemes. Where pharmacy staff were involved, they were valued by the teams and contributed to medicines reconciliation, risk management, and patient education.

Staff told us that a lack of access to direct pharmacy support for the supply of medicines on the Isle of Wight was impacting on peoples’ abilities to access treatments in a timely way. For example, staff would sometimes have to travel between multiple community pharmacies to source medicines for a patient before attending a patient’s home visit.

Medicines reconciliations were not always completed promptly. Staff prioritised this work based on risk, but there was no standardised approach across the service.

On the Isle of Wight, the HBPoS was frequently unavailable due to bed pressures, impacting access and patient flow. Storage of medicines in HBPoS were usually good, however at The Orchards HBPoS the storage was not appropriate. This was raised with staff who rectified this on site.

There was a lack of routine auditing of medicines optimisation being completed in crisis services.

However, there were some examples of good practice. Staff described person-centred approaches to managing disengagement, including family involvement and escalation to police where needed. Clozapine re-titration was managed safely in the community with shared responsibility between teams. Some staff used innovative tools, such as reminder clocks, to support adherence. The Portsmouth CRHTT had applied to conduct a quality improvement project looking at the interruption of medicines.

Overall, the service showed significant variation in how medicines were managed across crisis and HBPoS settings. While there were pockets of good practice, improvements were needed in a consistent approach to documentation and pharmacy support, to ensure people received safe and effective care.