East London NHS Foundation Trust

Updated 22 June 2023

We inspected East London Foundation Trust as part of our continual checks on the safety and quality of healthcare services. We also inspected the well-led key question for the trust overall.

We carried out announced inspections of the forensic inpatient or secure wards and wards for older people with mental health problems core services during this inspection. We chose these two core services as we knew there had been some challenges including serious incidents and we wanted to see how the trust had responded and if high quality care and treatment had been maintained.

The trust provides the following mental health services, which we did not inspect this time:

• Acute wards for adults of working age and psychiatric intensive care units
• Child and adolescent mental health wards
• Community-based mental health services for older people
• Community-based mental health services for adults of working age
• Community mental health services for people with a learning disability or autism
• Long stay or rehabilitation mental health wards for working age adults
• Mental health crisis services and health-based places of safety
• Specialist community mental health services for children and young people
• Wards for people with a learning disability or autism

The trust also provides the following community health services, which we did not inspect at this time:

• Adults
• Children, young people and families
• End of life care

The trust also provides GP services, which we did not inspect at this time.

Our overall rating of services stayed the same. We rated them as outstanding because:

• We rated safe, effective and responsive as good. We rated caring and well led as outstanding.
• We rated the forensic inpatient core service as outstanding overall. We rated the wards for older people with mental health problems core service as good overall. In rating the trust, we took into account the current ratings of the mental health and community health services which were not inspected this time.
• We found that despite the challenges of the pandemic, the trust had adapted, learnt and continued to make positive progress. We found that the trust had addressed all the areas where improvements were recommended at the previous well led review. In most cases the trust had gone the extra mile to ensure this was done in a manner which made a positive impact on people who use services and staff working for the trust. For example, throughout the inspection we heard about the use of trauma informed care and about work to improve the sexual safety of people using services.
• There had been significant changes in the executive leadership team and non-executive directors, these had gone well and provided an opportunity to improve the diversity of the board and introduce people with the breadth of experience needed to support the strategic direction of the trust. There had also been an expansion to the leadership capacity of the trust and the associated governance, for example the development of a directorate to oversee primary care and the introduction of a chief digital officer to the executive leadership team. The trust had well embedded clinical leadership and this had been further strengthened, for example in social work, allied health professionals and learning disability and autism.
• We found an overwhelmingly positive culture across the trust. Staff told us that they felt proud to work for the trust and we heard many examples of how they put the people who use services at the centre in their work. The senior leaders including the non-executive directors were open, friendly and approachable. They had worked hard during the pandemic to engage with services in person and remotely. People and teams were able to speak honestly and reflect on where improvements were needed and how this could be achieved. Freedom to speak up arrangements had been further developed and were well used.
• People participation had extended since the last inspection and we heard of many examples where co-production was taking place. The number of people participation leads across the directorates and services had grown. The peer support workers employed by the trust had doubled to around 80 people. The people participation team had responded to COVID 19 with the development of a befriending service which had recruited volunteers and made over 7000 calls to people who were lonely and isolated. An example of innovative co-production was the development of the service user accreditation scheme where service users had developed standards and 50-60 people had been trained to assess the services provided by the trust. The people participation team were supporting other trusts and providers to further develop their co-production work.
• We were inspired by the work being undertaken by the trust on race and privilege. This was connected to the Black Lives Matter movement and the work being done by the trust to improve staff well-being. There was a recognition that many of the black staff working for the trust were not alright and listening to their experiences. The trust was working towards the development of an anti-racist framework.
• Quality improvement continued to be embedded and developed further across all areas of the trust. People working for and associated with the trust talked about how the approach was widely used. This approach was being developed further to look at waiting lists for services especially as referrals were increasing. The trust was making data available to teams to help them use a structured approach to look at demand and capacity of services and develop individual plans to improve patient flow.
• Work to refresh the strategy was almost complete and had been done with a wide range of internal and external consultation. The strategy on a page was clear and accessible. It provided a focus for the work being done by the trust to meet the needs of local populations. The systems, directorates and services had developed aligned annual plans on a page identifying their priorities and key milestones. The trust employed public health clinicians and was partnering with the Institute of Health Equity at University College London to develop outcome measures for population health.
• The trust had made a significant contribution through its delivery of the vaccination programme in North East London. This had been delivered at large scale and at speed.
• Partnership working had developed significantly since the previous well led review. Senior leaders were actively participating and leading in the two care systems where the majority of trust services were located. The trust also had many examples of where it was working in boroughs and neighbourhoods to meet the needs of communities. The trust had taken over the provision of some GP practices and this was enhancing the opportunities to meet the needs of populations. Examples of this work was the Bedfordshire Care Alliance where improved system working was enabling more people with long term conditions to receive the support needed to stay in their own homes. The importance of partnership working was reflected in the addition of a new sub-committee of the board focusing on integrated care.

There were however areas for improvement:

• There were recurring themes linked to serious incidents. The trusts own recent deep dive had recognised this and identified actions to improve. A patient safety forum had been developed to support this work.
• Whilst there were plans for significant developments such as a new mental health inpatient service in Luton and Bedfordshire, some of the trusts existing estate required work to ensure they provided a therapeutic environment, for example the health based place of safety in Newham. A rolling programme for decoration was required at the John Howard Centre and works were needed at Fountains Court to comply with same sex accommodation guidance.
• Several staff told us about the frustrations they experienced in using trust IT systems. A chief digital officer had been appointed, a digital strategy was in place and work to improve the connectivity of teams and wards was underway. Systems to enable staff teams to access live data to inform their day to day work on screens and on mobile phones was due to happen shortly after the inspection was complete.
• Whilst the inspection identified these areas for improvement, the trust was already aware of them, had highlighted potential risks and how these would be mitigated and had plans in place for how they would be addressed.

How we carried out the inspection

During our inspection of the two core services, the inspection teams:

• reviewed records held by the CQC relating to each service
• visited 12 wards across the London boroughs of Hackney, Newham and Tower Hamlets and in Luton and Bedfordshire. We looked at the quality of the ward environment, management of the clinic rooms, and observed how staff were caring for patients
• interviewed the ward manager and/or matron on each ward
• spoke with 76 staff members including nurses, clinical practice leads, a physical health lead nurse, social therapists, support workers, occupational therapists, psychologists, consultant psychiatrists, a clinical pharmacist, an assistant pharmacy technical officer, art therapist and a speech and language therapist
• spoke with 10 senior members of staff including the head of forensic services, the head of nursing and associate clinical director for safety and security, the associate clinical director for therapies and recovery, the head of psychology, the lead pharmacist for forensic services, the sexual safety lead for forensic services and the drugs and alcohol lead for forensic services
• interviewed 47 patients and 11 relatives of patients
• reviewed 34 patient care and treatment records
• attended two multi-disciplinary team meetings, three ward rounds, two community meetings, one care programme approach meeting, a service referrals and move on meeting, a patient group, a people participation working together group, a carers’ forum, a service wide safety huddle, observed two ward based safety huddles and visited the patient shop at the Wolfson House site
• spoke with an independent advocate
• carried out a specific check of the medication management on Butterfield, Clissold, Westferry and Bow wards
• looked at a range of policies, procedures and other documents relating to the running of each service.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

During this inspection we spoke with 47 patients and 11 relatives of patients.

Overall, feedback from patients was very positive. Patients told us they felt safe, valued and respected. Patients said staff listened to how they were feeling and supported them to understand their care. They were positive about how caring, kind and approachable the staff were. One patient described how staff ‘went the extra mile’ when they were unwell.

Families were very positive about the service. Relatives said they found staff very supportive.

Updated 29 June 2025

We carried out an inspection of the trust’s community-based mental health services for adults of working age on 25 November to 27 November 2025. The community-based mental health services for adults of working age form part of the trust’s mental health services in the community. This inspection was completed as part of CQC's Adult Community Mental Health Programme. We also inspected mental health crisis services and health-based places of safety as part of the programme. The programme of inspections contributes to CQC's commitment to inspect the standard of care in community mental health services across the country. We undertook a short-notice announced, comprehensive inspection of this service, looking at all 5 key questions to assess if services are safe, effective, caring, responsive and well-led.

East London NHS Foundation Trust is part of the North East London Integrated Care System (ICS) and was part of the Bedfordshire, Luton and Milton Keynes ICS. Since April 2026, Bedfordshire, Luton and Milton Keynes ICShas been replaced with a new single organisation serving 3.5 million people across Bedfordshire, Luton, Milton Keynes, Hertfordshire, Cambridgeshire Peterborough called NHS Central East Integrated Care Board (ICB). There are 3 local authorities across Bedfordshire and Luton 1 of which is in the most deprived category of all local authorities in England.

The population of the North East London ICS area is over 2 million, with significant health inequalities across the 6 local authorities and City of London Corporation. Each local authority is more ethnically diverse than the national average. Three of the local authorities are in the most deprived category of all local authorities in England. Suicide rates within the ICS are lower than the national averages for both males and females across all local authorities and rates of emergency hospital admissions for self-harm are lower than the national average for both males and females across all local authorities.

The trust’s community-based mental health services for adults of working age are spread across 4 geographic localities:

• Bedfordshire and Luton
• Newham
• City and Hackney
• Tower Hamlets

The way in which services were organised and delivered varied across the 4 localities and across different teams. This included differences in governance systems.

Across the 4 localities the teams included community mental health teams (CMHT), early intervention services and recovery teams, as well as neighbourhood mental health teams, community integrated mental health teams and community mental health hubs. Neighbourhood mental health teams are local, community-based services that merge older community mental health teams and primary care into integrated hubs. Community integrated mental health teams are teams that work with primary care networks, or groups of GP practices, and are made up of a range of health and social care professionals who co-ordinate care packages and treatment. Community mental health hubs provide walk in options and are local centres that provide joined-up mental health, social care, and housing support.

In the Tower Hamlets locality was the Barnsley Street Neighbourhood Mental Centre. This was one of six pilot sites opening around the country and provided a range of mental health services. These included planned and drop-in sessions with psychiatrists, nurses, OTs, psychologists, social workers, voluntary sector and peer support workers.

We inspected the following teams:

Bedfordshire and Luton

• Ampthill CMHT (Bedfordshire)
• Beacon CMHT (Bedfordshire)
• Bedford DECAR Hub
• Bedford North CMHT
• Bedfordshire and Luton Mental Health and Wellbeing Services
• Bedfordshire Recovery Team
• Biggleswade CMHT (Bedfordshire)
• Crombie CMHT (Bedfordshire)
• Dunstable CMHT
• Early Intervention Service (Bedfordshire)
• Luton Community Mental Health Hub – North
• Luton Community Mental Health Hub – South
• Leighton Buzzard CMHT
• Meadow Lodge CMHT (Bedfordshire)
• Spring House CMHT (Bedfordshire)
• UNISE

Newham

• Community Integrated Mental Health Team (South)
• Community Integrated Mental Health Team (North)
• Community Recovery Team North (Newham)
• Early Intervention Service (Newham)
• Recovery Team South (Newham)

City and Hackney

• City Hackney Single Point of Access
• City and Hackney North CMHT
• City and Hackney South CMHT
• EQUIP Team (Early Intervention City Hackney)
• HEADS UP - Mental Health Early Detection Service (City Hackney)
• Neighbourhood Recovery Service

Tower Hamlets

• Barnsley Street Neighbourhood Mental Health Centre
• Bethnal Green Neighbourhood Mental Health Team
• Bow Poplar Neighbourhood Mental Health Team
• Early Intervention Service (Tower Hamlets)
• Isle of Dogs Neighbourhood Mental Health Team
• Stepney Wapping Neighbourhood Mental Health Team

At our last inspection, in June 2016, we rated the service as good overall. We rated safe, effective, caring and responsive as good and well-led as outstanding. There were no breaches of regulation. At this inspection the rating has changed to requires improvement. We rated safe, responsive and well-led as requires improvement. We rated effective and caring as good. We found 4 breaches of regulation relating to:

• incident reporting and investigation
• the deployment of sufficient staff, who had completed mandatory training and received supervision and appraisal
• timely access to appropriate care and treatment
• governance.

We have asked the provider for an action plan in response to the concerns found at this inspection.

Updated 16 December 2025

We assessed Community Health Service Adults from 20 to 22 January 2026.

We carried out a short notice announced inspection of community health services for adults as part of our continual checks on the safety and quality of healthcare services. We visited community health services for adults in Tower Hamlets, Newham and across Bedfordshire. We visited 7 district nursing teams, 2 tissue viability/leg ulcer services, 3 urgent community response teams and 3 community therapy teams.

We spoke to 20 patient’s, 44 carers and relatives. We reviewed 29 patients’ care and treatment records. We attended home visits with district nurses and physiotherapists, including observing medication administration. We carried out a tour of the environment at each site we visited. We observed handover meetings, allocations meetings, risk meetings, and safety huddles. We spoke with 83 staff members including a clinical director, clinical leads, community matrons, nurses, non-medical prescribers, physiotherapists, occupational therapists, care navigators, health care assistants, tissue viability nurses and diabetes specialist nurses.

We had previously inspected community health services for adults in September 2016. As a result of that inspection, we had rated the safe domain as requires improvement. The trust was in breach of regulation 12, as staff did not maintain appropriate patient care and treatment records. We had rated the effective, caring, responsive and well led domains as good. Our overall rating was good.

At this inspection our ratings changed. Our rating for safe improved, this domain was rated as good and there was no longer a breach in regulation. Ratings for effective, caring, responsive and well led stayed the same and were rated as good. Our overall rating stayed the same, and the service was rated as good.

People were protected from avoidable harm. Staff recognised and managed risks well, including risks associated with pressure damage, deterioration and safeguarding. Care records supported safe practice, and systems for reporting, learning from and responding to incidents were well embedded. Since the last inspection, improvements had been made and the service was no longer in breach of regulation.

Care and treatment was effective. Staff assessed people’s needs thoroughly and worked well together across teams and with partner organisations to deliver joined-up care. This helped people to avoid unnecessary hospital admissions and supported timely discharge from acute services.

People who used services and those close to them were active partners in their care. Staff treated people with kindness, compassion and respect. People consistently told us they felt listened to, involved in decisions about their care and supported to maintain their independence. The caring culture across the services was a strength, with staff consistently meeting people’s emotional, cultural and social needs.

Services were responsive to people’s needs. Care was person-centred, and staff acted promptly when people’s condition changed. Waiting times were monitored, urgent referrals were prioritised appropriately and missed visits were rare. Staff had introduced improvements in response to feedback from patient’s and carers.

The service was well led. Leaders were visible, approachable and understood the challenges facing community services. Governance arrangements provided reasonable assurance of safety and quality, and partnerships with acute trusts, primary care, ambulance services and social care supported coordinated care. Staff felt supported and valued, although ongoing pressures from increasing demand and workforce challenges meant leaders needed to continue focusing on staff supervision, capacity and sustainability.

However,

Although supervision compliance was improving, it remained below the trust target during the inspection, and the trust needed to continue to strengthen systems to ensure all staff received regular supervision.

Information leaflets were not always available in languages spoken by patients. The trust recognised this and was working to improve access to translated materials.

Updated 18 November 2025

Our view of this service

Date of inspection: 8-18 December 2025.

East London NHS Foundation Trust provides inpatient psychiatric treatment and care for male and female patients, many of whom are detained under the Mental Health Act 1983.

These services comprise total of 21 acute wards and 5 psychiatric intensive care units (PICU) for working-age adults located across East London, Luton and Bedfordshire:

• City Hackney Centre for Mental Health, London (5 acute wards, 1 PICU)
• Newham Centre for Mental Health, London (2 triage, 4 acute, 1 PICU)
• Tower Hamlets Centre for Mental Health, London (4 acute wards, 2 PICU)
• Luton Centre for Mental Health, Luton (3 acute wards, 1 PICU)
• Oakley Court and Townsend Court, Central Bedfordshire (3 acute wards).

We carried out inspection visits to the wards operated by the Trust from 8 to 18 December 2025. We visited 16 of the above wards:

City and Hackney, London

• Joshua (19-bed male acute ward)
• Conolly (18-bed female acute ward)
• Gardner (20-bed female acute ward)
• Bevan (15-bed male PICU)

Newham, London

• Ruby (15-bed male triage ward)
• Ivory (15-bed female triage ward)
• Emerald (18-bed female acute ward)
• Crystal (15-bed male PICU)

Tower Hamlets, London

• Globe (19-bed male acute ward)
• Roman (19-bed female acute ward)
• Rosebank (11-bed female PICU)
• Millharbour (11-bed male PICU)

Luton Centre for Mental Health

• Coral (21-bed male acute ward)
• Jade (9-bed male PICU)

Oakley Court, Bedfordshire

• Ash (19-bed female acute ward)

Townsend Court, Bedfordshire

• Townsend (20-bed female acute ward).

We announced our inspection shortly before our team arrived on site. We also carried out unannounced visits at night to Bevan, Joshua, Emerald, Ivory and Crystal wards.

The services were last comprehensively inspected in 2016 and rated outstanding overall, with no breach of regulations. We since carried out several focused inspections. These inspections did not result in us re-rating the service, however, following our inspection in 2023, we limited the rating for safe to requires improvement. At that time, we found breaches of regulation because the trust did not always meet its targets for compliance with staff mandatory training and supervision.

This inspection was comprehensive and covered all key questions and quality statements. We have combined the scores for these to achieve the overall rating. Following this inspection, the overall rating has changed to requires improvement.

We found breaches of regulations in relation to safe care and treatment, premises and staffing:

• Regulation 12: Safe care and treatment. Post-rapid tranquilisation (RT) records had not been completed correctly. Physical health monitoring for patients prescribed high-risk medicines was inconsistent. Risk assessments for prescribed medicines with known side effects were not consistently completed. Legal documentation was not completed correctly, resulting in medicines being administered unlawfully.

• Regulation 15: Premises. Not all premises where care and treatment was delivered were fit for purpose, properly maintained and free from offensive odours. Adequate toilets and bathrooms were not available to people using the service. There were sometimes delays in maintenance work taking place.

• Regulation 18: Staffing. Further work was needed to ensure all staff completed mandatory training and received regular supervision and appraisal.

We have asked the provider for an action plan in response to the concerns found at this inspection.

We found other areas that needed improving to meet best practice standards. We identified some gaps in safety checks on several wards. Record keeping around ‘when required’ (PRN) medicines was inconsistent. Intermittent observations were carried out at set intervals, making them predictable. Signage to say that informal patients could leave was not in place on all wards. Care was not always delivered in a person-centred way. Patients were moved without notice between Ash and Willow wards in response to bed pressures. Some discharges were delayed due to factors outside of the trusts control. We saw limited evidence of patient and carer voice or co-production at service level, and variation in how well Patient and Carer Race Equality Framework (PCREF) was embedded across the wards.

We also found areas of good practice. During our visits the wards were fully staffed. Staff reported an open and supportive culture where learning was shared. Staff regularly met as a team to discuss patient risks and share information. Staff worked well with other teams within the trust and externally. Wards participated in quality improvement and accreditation. Resuscitation simulation training was regularly delivered to staff on London wards.

Mental Health Act and Mental Capacity Act Compliance Summary

Mental Health Act

The service provides care to patients detained under the Mental Health Act 1983 (MHA) as well as informal patients.

Staff received mandatory training in the MHA and its guiding principles. Overall, 97% had completed this. Staff had easy access to administrative support and legal advice on implementation of the MHA and its Code of Practice. Staff requested support from a second opinion appointed doctor when necessary. Staff stored copies of patients' detention papers and associated records appropriately.

Records showed that staff explained to patients their rights under the MHA in a way that they could understand, repeated as necessary and recorded that they had done so.

However, consent to treatment authorisations were not always completed correctly, which meant that medicines were administered unlawfully. On Townsend, Globe, Roman and Jade wards patients were prescribed medicines that had not been authorised or with medicine indication information not completed.

The majority of patients and carers we spoke with reported not having information about Independent Mental Health Advocacy (IMHA) or not being aware of what it was. This was not in line with the statutory rights of qualifying patients detained under the MHA.

Staff ensured that patients could take Section 17 leave (permission for patients to leave hospital) when this had been granted.

Mental Capacity Act

We saw evidence that staff assessed and recorded capacity to consent appropriately for patients who may have had impaired mental capacity. Capacity was assessed for each significant decision that a person needed to make.

Staff had completed mandatory training in the Mental Capacity Act (MCA). Overall 83% were up-to-date with this. There were variations in compliance rates for this training, across Luton and Bedfordshire wards 72% of staff were compliant and on Lea Ward in Tower Hamlets, 73% of staff had completed this. In Luton and Bedfordshire, 50% of medical staff had yet to complete their MCA training.

Updated 19 January 2026

We carried out a comprehensive assessment of the East London NHS Foundation Trust, Child and adolescent mental health inpatient wards across two locations: The Coborn Centre for Adolescent Mental Health in Newham, and Evergreen Unit for Adolescent Mental Health in Luton.

We inspected this service as part of our ongoing comprehensive mental health inspection programme.
The units deliver the following regulated activities:
• Treatment of disease, disorder or injury
• Diagnostic and screening procedures; and assessment or medical treatment of persons admitted under the Mental Health Act (MHA) 1983
The Coborn Centre and the Evergreen units provide specialist Tier 4 Child and Adolescent Mental Health Services (CAMHS) inpatient care for adolescents experiencing severe and complex mental health disorders. The service delivers assessment, care and treatment for young people whose mental health needs and associated risks cannot be safely or effectively managed within community settings. Care is delivered using a community-oriented model underpinned by trauma-informed practice, co-production with young people, and active involvement of parents and carers in care planning and decision-making processes.
The units accept referrals for young people aged 13 years and above. At the time of inspection, the youngest admitted patient was 14 years old. There were no patients aged 18 years on the wards during the inspection
The service provides care and treatment for a range of mental health presentations including emotional dysregulation, depressive disorders, psychosis and eating disorders. Young people admitted to the service commonly present with significant functional impairment and elevated levels of risk to themselves and/or others.

We visited the following units as part of the assessment:
Four units at the Coborn Centre for Adolescent Mental Health (Newham, East London)
• Nova Ward (previously Coborn Acute Ward) 12 - bed acute inpatient
• Pluto Ward (previously Coborn PICU Ward) 4 - bed Psychiatric Intensive Care Unit (PICU)
• Galaxy Ward 11 - bed Psychiatric Intensive Care Unit (PICU)
• Day Unit for 6 young people
The Evergreen unit (Luton)
• 8 - bed adolescent inpatient ward.
The East London NHS Foundation Trust, child and adolescent mental health Inpatient wards were last inspected in June 2016, at which time the service was rated as Outstanding overall. The most recent Mental Health Act review visits took place at the Coborn Center Unit in March 2024 and at the Evergreen unit in May 2023 respectively.
During this assessment, the inspection team:
• Visited 4 wards and 1 day unit across the 2 hospital sites
• Carried out an environmental tour of each of the wards and observed staff supporting and interacting with the young people.
• Spoke with 16 young people
• Spoke with 5 carers
• Spoke with 48 members of staff. This included ward managers, consultant psychiatrists, senior leadership team, mental health law team, support workers, people participation lead, deputy director, lead psychologist, lead social worker, assistant clinical director, registered nurses, clinical lead nurse, nurse associate, health care assistants, art and drama therapist, care managers, education lead, practice lead, life skill recovery worker.
• We attended multi-disciplinary meetings, senior management group (SMG) daily meeting, interface meeting with the North Central and East London (NCEL) Provider Collaborative, risk management meetings, safety huddles, ward rounds community meetings, education and activities.
• We looked at policies and procedures related to the running of the service.
• We reviewed the restraint tracker,
• We reviewed 7 seclusion records
• 16 electronic care records including NG tracker, incidents review and safeguarding records.

The service demonstrated a strong commitment to therapeutic recovery through the delivery of psychological interventions, educational provision, occupational therapy and structured therapeutic activities, alongside pharmacological treatment where clinically indicated. We observed strong and effective multidisciplinary working across both sites. Meetings we attended were collaborative, well-structured and clearly focused on the best interests of the young person. There was clear communication between disciplines, including psychiatry, psychology, nursing, occupational therapy and education staff, enabling a comprehensive and shared understanding of risk and care needs. Staff demonstrated a proactive and coordinated approach to risk management, with thorough discussions of risks, triggers and care planning interventions.

Interactions between nursing, the multidisciplinary team and the wider clinical teams were consistently positive, with good rapport observed and reflected in feedback from young people. Staff across both services demonstrated a shared commitment to delivering person-centred care. The integration of the Coborn Centre and Evergreen Unit supported a consistent approach to ethos, values and governance, strengthening collaboration and alignment across sites.

The service also demonstrated a strong commitment to learning, improvement and innovation. There was evidence of well-established quality improvement work, including initiatives to reduce restrictive practices, improve therapeutic engagement and enhance patient experience. These initiatives were supported by co-production with young people and reflected a proactive approach to continuously improving care and outcomes.

Updated 7 July 2025

We carried out an inspection of the trust’s mental health crisis services and health-based places of safety on 25 to 27 November 2025. The mental health crisis services and health-based places of safety form part of the trust’s mental health services in the community. This inspection was completed as part of CQC's Adult Community Mental Health Programme. We also inspected community-based mental health services for adults of working age as part of the programme. The programme of inspections contributes to CQC's commitment to assess the standard of care in community mental health services across the country. We undertook a short-notice announced, comprehensive inspection of this service, looking at all 5 key questions to assess if services are safe, effective, caring, responsive and well-led.

East London NHS Foundation Trust is part of the North East London Integrated Care System (ICS) and was part of the Bedfordshire, Luton and Milton Keynes ICS. Since April 2026, Bedfordshire, Luton and Milton Keynes ICS has been replaced with a new single organisation serving 3.5 million people across Bedfordshire, Luton, Milton Keynes, Hertfordshire, Cambridgeshire Peterborough called NHS Central East Integrated Care Board (ICB). There are 3 local authorities across Bedfordshire and Luton, 1 of which is in the most deprived category of all local authorities in England.

The population of the North East London ICS area is over 2 million, with significant health inequalities across the 6 local authorities and City of London Corporation. Each local authority is more ethnically diverse than the national average. Three of the local authorities are in the most deprived category of all local authorities in England. Suicide rates within the ICS are lower than the national averages for both males and females across all local authorities and rates of emergency hospital admissions for self-harm are lower than the national average for both males and females across all local authorities.

The trust’s mental health crisis services and health-based places of safety are spread across 4 geographic localities:

• Bedfordshire and Luton
• Newham
• City and Hackney
• Tower Hamlets

The way in which services were organised and delivered varied across the 4 localities and across different teams. This included differences in governance systems.

In Bedfordshire and Luton locality there were 2 Crisis Resolution Home Treatment (CRHT) teams who worked with people in mental health crisis to support them in their own homes. In Newham, City and Hackney and Tower Hamlets localities, mental health crisis services were provided by Home Treatment Teams (HTT) and Crisis Assessment Teams (CAT). HTTs worked to support people in mental health crisis in their own homes. CATs carried out urgent assessments for people presenting in mental health crisis.

The trust operated 2 NHS 111 option 2 telephone services for people to call when experiencing a mental health crisis. These operated 24 hours a day, 7 days a week and were based in Tower Hamlets and Bedfordshire and Luton localities. The 111 option 2 service in Tower Hamlets provided the crisis phone line for the trust and a neighbouring NHS trust.

The trust had 2 health-based places of safety (HBPoS) at City and Hackney Centre for Mental Health and Luton and Central Bedfordshire Mental Health Unit. Health-based places of safety, otherwise known as 136 suites, are used if someone is detained by police under Section 136 of the Mental Health Act 1983, to remain for a maximum of 24 hours until a Mental Health Act assessment is undertaken.

At our last inspection, in June 2016, we rated the service as good overall. We rated safe, effective, caring and well-led as good and responsive as outstanding. There were no breaches of regulation. At this inspection the rating changed to requires improvement. We rated safe, effective, responsive and well-led as requires improvement. We rated caring as good. We found 5 breaches of regulation relating to:

• the suitability of environments, including lack of access to fresh air in the HBPoS
• the deployment of sufficient staff
• consent and use of the Mental Health Act
• timely access to appropriate care and treatment
• governance.

We have asked the provider for an action plan in response to the concerns found at this inspection.

Updated 1 September 2016

Overall rating for this core service Good because:

• The children and young people services (CYP) had good processes for reporting and learning from incidents. There were robust child safeguarding systems.
• Staffing levels were good, with good recruitment and retention of staff. Caseloads were well managed.
• There were effective systems to protect staff and manage risk appropriately. There was good compliance with hygiene and infection control processes.
• CYP practitioners provided competent, thorough and evidence based care and treatment in line with national guidance. CYP services used nationally recognised outcome measures to monitor performance.
• There was effective internal and external multidisciplinary team working.
• Staff sought patients’ consent to treatment and recorded this appropriately.
• Staff were supportive and caring of clients and families they worked with, and provided patient-centred support in both clinics and in homes. Clients were very happy with the care and treatment provided.
• Staff planned and delivered services in line with local needs. Service users could access a range of CYP services in a number of locations. There was good understanding of the different cultural needs and backgrounds of clients. There was good access to translation services. There was good provision of services and support for vulnerable client groups.
• Staff told us that service leaders were very supportive, accessible and approachable. Staff reflected the trust values and vision. The CYP service worked in partnership with clients and the local community to improve services and health outcomes. There was an appropriate strategy in place for the CYP service.
• There were really robust governance structures and systems in place for the review of performance and risk management information. The information supported the management of the services and was accurate and in an accessible format. Service changes and improvements took place as a result of these governance processes.
• Staff really valued working for the trust and there were different ways in which the trust engaged with staff including their participation in focus groups.
• The trust sought feedback from people using the service and engaged them in work to improve services. Changes were made as a result of this input.
• The service was constantly innovative and actively participated in quality improvement projects. For example the team supporting patients with sickle cell had initiated and hosted an annual conference for several years to share good practice.

However:

• The health centres where the CYP services held clinics were not always safe or child friendly. These environments were in the process of being upgraded.
• Staff did not always recognise the terminology of ‘duty of candour’ although they understood and implemented an open, honest approach which acknowledged with patients when things went wrong.
• There were insufficient arrangements for client transition from paediatrics to adult services because of uncommissioned gaps for 16-17 year olds in therapy service provision. This was an issue the trust had raised with commissioners.
• There were some instances of ineffective communication by practitioners; particularly in situations where both practitioner and client did not speak English as a first language.
• At the time of the inspection some service redesign was taking place as a result of decisions made externally to the trust and a few staff felt that the engagement and consultation linked to this could be improved.

Updated 1 September 2016

Overall we rated this service as good because:

• Staff promoted the privacy and dignity of patients. We also observed staff to be caring in their interactions with patients. All the patients we spoke with told us that staff were kind and treated them with respect. We did not come across any examples where this was not the case. Patients and relatives felt involved and included.

• Services were safe. There was a good culture for the timely reporting of incidents including all serious incidents and the trust were able to identify themes and trends across community inpatient services. Safeguarding processes enabled the identification of possible abuse and encouraged reporting. Processes for the safe administration of medication were in place. Patient records were up to date, written legibly, dated and signed. Wards were clean and staff were trained in infection prevention and control. The wards were fully staffed and there were enough staff to meet the needs of the patients. .

• The wards delivered care in line with current national guidelines. Patients received timely pain relief. Staff understood the importance of nutrition and hydration. Patients received adequate assistance to eat and drink. Staff were also able to access key skills training appropriate to their role.

• Patient admissions and discharges were appropriately planned and managed to ensure effective care and transition with the acute hospital and community services. Staff understood their roles in regards to patient consent and capacity. There was good multi-disciplinary working and inter-agency working.

• The wards were meeting the needs of vulnerable people. For example, a range of ‘easy read’ and braille information was available to patients. Community therapy assessments had taken place and the multidisciplinary team was involved in preparations for discharge. Patients reported that their care and treatment needs were being met. It was reported that call bells were responded to appropriately and night staff were also responsive.

• Staff reported to us that they had confidence in their leadership, who they found responsive, and that members of the executive team were visible. There was a governance structure that enabled managers and senior managers to appropriately monitor and review the quality of service provision.

However:

The treatment rooms where medication was stored were too hot. Trust managers were aware of this and taking steps to ensure the rooms were an appropriate temperature. 

Updated 1 September 2016

We gave an overall rating for the specialist community mental health services for children and young people of outstanding because:

• Staff treated young people and their families as partners in their care. They understood the importance of being kind and respectful. There was genuine empathy and understanding of individual needs and wishes, which was reflected in the work undertaken with young people and their families.

• Managers supported staff to deliver effective care and treatment. Staff adopted a multi-disciplinary and collaborative approach to care and treatment. There was strong leadership at both local team and service levels, which promoted a positive culture. There was a commitment to continual improvement across the services. Managers recognised the importance of consulting with staff in the development of services.

• There were clear processes in place to safeguard young people and staff knew about these. Incident reporting and shared learning from incidents was evident in all services. Teams considered the review of incidents to be an opportunity for learning. There was good evidence of learning and improvements following incidents both within ELFT and in other trusts. CAMHS teams used learning from national inquiries to make improvements. For example, Lord Laming’s report on the Victoria Climbie. There were regular learning events in teams.

• Most young people, children and families could access services promptly. Where there were improvements to be made, CAMHS teams had used the quality improvement methodology and had adopted a systematic approach to bring about these improvements. There were robust systems in place in all teams to manage referrals and waiting lists. Staff worked to ensure that young people attended their appointments. The numbers of patients who did not attend were closely monitored.
• Staff were proactive in identifying trends amongst the young people they worked with and were working collaboration with other agencies to ensure that emerging needs were met. CAMHS staff were forward thinking in their approach and looked at how to improve accessibility for young people who might find it hard to engage. For example they were looking at developing a smartphone application . Staff were doing this in their own time.
• CAMHS teams were aware of the diverse needs of people using the services. Individual teams had undertaken work to ensure that diverse needs were met. For example, Tower Hamlets CAMHS had looked at the needs of the Bangladeshi community and their access to community services. They produced a report that identified that the young people were under-represented within the client group. City and Hackney CAMHS had identified that African Caribbean boys were at risk of becoming involved in gang related activity and were working with statutory partners and the voluntary sector to target these young people. Groupwork programmes were run in other languages, for example, Bengali.
• The importance of service user participation was a strong feature of the work undertaken by CAMHS. The participation worker in Luton and Bedfordshire had worked with a young person to write a training package about discrimination and confidentiality. There were specific pilots in other CAMHS teams for phobic children.
• Teams were conscious of the trends amongst the young people they worked with and endeavoured to respond to these in a timely manner. For example in Bedfordshire, a particular school had reported an increase in the number of young people who had self-harmed. The team had provided training to the school. The team was also running a pilot programme with a school to look at the issues relating to online bullying and with another school regarding child sexual exploitation as there had been an increase in these cases in the county. The team were also working with the National Society for the Prevention of Cruelty to Children to support these young people. There was strong working relationship between Bedfordshire CAMHS and the family nurse partnership (FNP). FNP provide a programme for vulnerable young first time mothers. The partnership between the team and FNP meant that staff were able to offer support to teenage mothers who may be experiencing postpartum depression or other mental health problem.

However:

• Administrative staff in Luton and Bedfordshire CAMHS experienced low morale. They were going through changes in how their work was delivered.

• Not all staff had completed safeguarding children levels 2 and 3training although safeguarding practice was good and further training was planned.

Updated 26 June 2018

A summary of this service appears in the Overall Summary.

Updated 1 September 2016

We rated community-based mental health services for older people as good because:

• Staff were providing a safe service. Staff were aware of the risks for individual patients, medication was managed well and staff had a good understanding of safeguarding. Staff were mostly able to see patients in a timely manner and prioritised people who needed urgent support.

• Staff were consistently caring and showed warmth, kindness and respect to patients and their carers. They provided practical and emotional support. There was good evidence of patient and carer involvement in all aspects of their own care including the development of their care plans. Staff went the extra mile to care for patients in a holistic and person centred way. They were very mindful of peoples needs based on their religion, culture, disabilities and relationships. Training courses and accessible information was provided for patients and carers. The needs of carers were assessed and support groups were provided.

• Practice reflected current guidance and there was good access to a wide range of interventions. There was good use of outcome measures to monitor if services were effective. Audits that were specific to the service were carried out to provide assurance of robust care with improvements made where needed.

• Staff morale was very good. They were well supported with access to training, supervision and other opportunities to reflect and learn. Innovations to support staff such as the use of mindfulness were in place. There were opportunities for leadership training and career progression.

• The teams worked well with GPs, the local authorities and other local services and groups. This enabled patients and their carers to experience a more joined up service.

• Patients, carers, staff and external stakeholders were encouraged to give feedback through a range of mechanisms and these were used to make improvements.

• The quality improvement programme in the trust encouraged innovation and examples of this was seen across the services.

However:

• Whilst achieving targets for assessments and diagnosis for memory clinics were being robustly tackled with action plans in place, there was still work to do to consistently provide a responsive service especially across the Bedfordshire teams.

Updated 26 June 2018

A summary of this service appears in the Overall Summary.

Updated 13 January 2022

Updated 1 September 2016

We rated long stay/rehabilitation mental health wards for working age adults as good because:

• Staff on both wards promoted the privacy and dignity of patients. Staff were kind and caring in their interactions with patients and relatives. All the patients we spoke with were positive about staff and said they treated them with respect. Both wards had a staff member who was the designated carer lead. Patients and relatives felt involved and included in decisions about care and treatment.

• The wards were safe. Staff reported incidents appropriately and in a timely manner. Staff understood and implemented trust safeguarding procedures. This allowed the identification of possible abuse and protection of patients. Medicines were stored safely and staff administered medicines as prescribed. Wards were clean and staff carried out regular infection control audits.

• Patients had good access to physical healthcare including access to specialists when needed. Staff used the national early warning score and escalated concerns to medical staff when required. Patients were supported to self-medicate at 105 London Road. Both wards had effective relationships with community care-coordinators and local voluntary sector organisations who provided support to patients on the wards and in the community. Care plans were holistic and person centred.

• Both wards were spacious with a full range of rooms to support treatment and care. Information on how to complain was displayed in communal areas on both wards. Patients had access to appropriate spiritual support. 105 London Road also had a spiritual kindle for patients to read scriptures on. Staff could access interpreters and knew how to download patient information in different languages.

• Staff reported to us that they had confidence in their leadership, who they found responsive, and that members of the executive team were visible. Senior managers visited the wards and attended ward team meetings. There was a governance structure that enabled managers and senior managers to appropriately monitor and review the quality of service provision.

However:

• At 105 London Road, the Section 17 leave documentation did not always make completely clear the extent or boundary of where detained patients could go when they left the ward. Staff told us that leave defined as within the ward boundary also included the local shop which was more than five minutes walk away and outside the boundary of the premises. Also, staff at 105 London Road had not completed a risk assessment of all detained patients immediately before they took section 17 leave.

• It was difficult for patients to access psychological therapies as there was no psychologist in the multidisciplinary teams. There was a risk that this would limit patients’ access to NICE recommended therapies such as cognitive behaviour therapies and family interventions.

• Some individual patient care plans did not record clearly defined and measurable recovery goals for all the needs identified. This made it difficult for staff to evaluate the progress patients were making in some areas.

Updated 13 January 2022