East London 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 means we looked for evidence that people were protected from abuse and avoidable harm.

At our last inspection we rated this key question good. At this inspection the rating has changed to requires improvement. We found 2 breaches of regulations in relation to incident reporting and investigation and providing sufficient staff, who had completed mandatory training and received supervision and appraisal.

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

The service did not always ensure safety incidents were reported and investigated thoroughly. Staff did not follow clear processes for people who disengaged from services. The service did not always make sure facilities supported the delivery of safe care. The service did not always deploy sufficient staff, who had completed required mandatory training, nor received regular supervision and appraisal. The service did not consistently promote the welfare of staff who were required to work alone.

However, staff acted to safeguard people using services, sharing concerns quickly and appropriately. The service mostly worked well with people to understand and manage risks. The service mostly assessed and managed the risk of infection. The service mostly ensured that medicines and treatments were safe and met people’s needs, capacities and preferences.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a proactive and positive culture of safety based on openness and honesty. Though they listened to concerns about safety, they did not always investigate or report safety events. Lessons were not always learnt to continually identify and embed good practice.

Staff reported incidents using an online incident reporting system, however, they did not always ensure incident reports were categorised in a way that ensured there was an appropriate response. They categorised incidents as either those which met the criteria for reporting to the national Learning from Patient Safety Events (LFPSE) system or as ‘Non-LFPSE’. LFPSE is a national NHS system for the recording and analysis of patient safety events that occur in healthcare.

The service reported 262 incidents between September and November 2025, of which 189 were categorised as LFPSE and 73 as non-LFPSE. These incidents that the service had categorised as non-LFPSE were reviewed and 5 incidents were identified which could potentially have met the LFPSE definition of a patient safety event. These varied in theme and no consistent pattern was identified in the types of incidents affected. This meant we could not be assured the service consistently recognised or recorded the correct severity for incidents. There was a risk incidents of the highest severity may not be recognised and therefore appropriate action to investigate and learn from incidents could not be taken. Following our inspection, the trust told us they were currently reviewing the incident reporting process, and considering options that could reduce the risk of incorrect initial categorization.

The service reported 22 patient safety incidents categorised as severe harm or death between December 2024 and November 2025. We reviewed the patient safety incident investigations (PSII) reports for 5 incidents. Each was led by a senior lead investigator who was trained to conduct investigations and identify learning. All relevant staff and stakeholders were included and their views reflected in the report. People using services and their families and carers were invited to be part of the investigation and were offered a copy of the report. The reports contained an apology for shortcomings in care and any distress caused. They also included a summary action plan. However, action plans were brief and did not always identify how actions would be reviewed and measured. Actions identified did not have implementation dates. Following our inspection, the service told us action progress and completion was monitored through the online incident reporting system and they were reviewing the PSII template to ensured it aligned with trust systems. They told us all PSII actions were reviewed by senior staff at the ‘sign-off panel’ to ensure they were specific, measurable and aligned to the findings of the investigation. The trust was developing a ‘reliability and maturity’ tool to look at patient safety initiatives in the trust and there was an ongoing quality improvement project focused on improving the quality of action plans.

The trust Patient Safety Incident Response Framework (PSIRF) policy stated there should be ‘awareness among all staff, including bank, locum, voluntary, and agency staff, of the communication systems in place for managing incidents, supported by appropriate induction and training.’ PSIRF is the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. The service provided training on the online incident reporting system to new and existing staff. The trust also provided training to develop staff knowledge, skills and competencies in line with PSIRF through training in 72 hour reports and after action reviews (AARs). An AAR is a learning response method that supports organisations to respond to a safety event.

The service reviewed incidents reported on the online incident reporting system daily against priority areas identified in the trust PSIRF policy. This included self-harm resulting in moderate or above physical harm and allegations of assault by staff on people using services. In each locality learning from incidents and 72 hour reports were discussed at locality level governance meetings. The meetings analysed incident trends by type of incident and service. The information was shared with the wider trust at the monthly quality assurance committee.

Managers were supported to investigate incidents and each locality had managers who were trained to carry out AARs. Staff told us they were involved in incident investigations and supported through them. They confirmed they were offered debriefs following a patient safety incident categorised as severe harm or death. They gave examples of incidents where staff from different teams across the trust were involved to identify learning and good practice.

Staff told us they were encouraged to report incidents and gave examples of learning from incidents in their teams. For example, staff at the Tower Hamlets early intervention and detection team told us that a recent incident had prompted a team discussion about using psychology input on home visits.

The service had zero never events in the last 12 months. Never events are defined as wholly preventable patient safety events.

The service received 1 prevention of future deaths report in October 2025 related to a death by suicide in May 2025. A prevention of future deaths report is a report made by a coroner to relevant authorities to attempt to prevent future deaths from causes identified during an inquest. The coroner found that the service should have considered the impact of changing medication on the person’s risk level. At the time of our inspection the service had not submitted an action plan to address these concerns as it was not due until the end of December 2025. However, the trust provided their 72-hour report which is an initial, rapid review conducted by a healthcare team immediately following a serious patient safety incident. Immediate actions included offering more frequent medical reviews in response to increased risks, The trust also advised that in the interim, the team continue to monitor and mitigate patient risk through established processes. The clinical director also communicated with the service that any significant proposed change to medication should be considered and discussed as part of the decision making process related to care planning.

Senior leaders met quarterly to discuss learning from deaths. We reviewed the minutes of the last 3 meetings and found relevant staff attended and the service considered social factors and health inequalities data in looking at learning from expected and unexpected deaths.

The trust provided their draft suicide prevention strategy. The aim of the strategy was to reduce suicide risk ‘through compassionate, evidence-based, and inclusive care, in line with trust values and national strategy and best practice’. Data from the National Confidential Inquiry into Suicide and Safety in Mental Health annual report 2025 showed the trust suicide rate was 3.08 per 10,000 people under mental health care, with the national median being 4.39. The trust told us it was reviewing its training plan for staff on suicide prevention and awareness.

The service provided data showing there were 45 incidents in the last 12 months which required duty of candour to be followed. The duty of candour is a legal obligation for healthcare providers to be open and honest with people who use services, or their families, when something goes wrong with their care or treatment and causes harm or has the potential to cause harm. Staff identified incidents which required duty of candour on the online incident reporting system. This was monitored by the trust governance and risk team through a daily incident review process. An overview of compliance with duty of candour across the trust was presented in the annual patient safety report to the quality and assurance committee.

The service worked well with people and healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the person being referred was received to determine if their needs could safely be met. For example, managers from the neighbourhood community mental health teams met with ward staff including staff from bed management, patient flow, and the discharge co-ordinator 3 times a week to discuss inpatients that would soon be discharged into the community. This was to ensure they knew the person and received all relevant information about them.

Staff involved all the necessary health and social care services to ensure people had continuity of safe care, both within the service and post-discharge. Teams across the service had made improvements to discharge planning, and had discharged a number of people over the year leading up to our inspection. For example, the Tower Hamlets early intervention service reduced their caseload from 240 to 191 since April 2024. However, staff in other teams, including the Early Intervention Service (Bedfordshire), and Luton Community Mental Health Hub – North and South, told us there had been an increase in referrals over the year prior to our inspection and their team caseloads were higher than what they were commissioned for. Following our inspection the trust told us the high caseload of the Early Intervention Service (Bedfordshire) team had been discussed at senior level and steps were taken to reduce the number of referrals, including recruiting additional staff to support the team. The service also created a dedicated workstream to improve caseload management across the trust. This would define, standardise and embed best practice caseload management across the service.

People were discharged from the services when the agreed interventions had been completed and their mental health was stable. The decision to discharge someone from the service was made by the multidisciplinary team. Staff assured people being discharged that they could return to the service if their conditions deteriorated. The service held regular meetings with voluntary and community sector organisations to discuss people being referred to their services after discharge. The early intervention services provided a three-year programme of enhanced support. Some of these people were referred for continuing support from community mental health teams. Others were discharged to the care of their GP.

Staff followed local processes for people who did not attend appointments or who disengaged from services. Managers from teams across the service told us that where people who required a follow up but had not been seen was due to ongoing non-engagement, including repeated Did Not Attend (DNA) occurrences despite multiple attempts by services to make contact. In some cases, follow-up activity was offered but declined by the person, or contact had not progressed due to changes in circumstances such as relocation, transfer of care or incarceration. Managers monitored caseloads to provide assurance that these cases were appropriately monitored. This included regular team caseload review meetings and structured table-top exercises within teams. During our inspection staff told us a decision to discharge following non-attendance was made on an individual basis. Following our inspection, the service provided information that showed there were documented procedures for disengagement and escalation in each locality, with decisions based on clinical need and risk. The trust had a group looking at developing a standardised approach to people who may need an assertive approach.

The service had shared care agreements with primary care networks across all geographic areas. A shared care agreement isa formal arrangement where an NHS trust specialist initiates treatment and, once the person is stable, transfers responsibility for ongoing prescribing and monitoring to the GP.

There were difficulties in finding places for people who needed admission to hospital, although staff said that if an urgent admission was required, this was prioritised. Managers told us there were delays in obtaining warrants and arranging police attendance at people’s residence. Once a person had been assessed as needing a Mental Health Act assessment, they were given the highest priority and contacted daily by the team managers. Managers told us there were no delays in accessing an approved mental health practitioner or doctors. However, the service did not monitor how long people were waiting in the community for a hospital bed.

Staff referred people to specialist services when necessary. For example, staff referred people for assessment for autistic spectrum disorders when this was appropriate.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately. However, not all staff were up to date with their mandatory safeguarding training.

The trust had up to date policies for staff to follow on safeguarding adults and children, which followed relevant national guidance and best practice.

Staff were trained in safeguarding adults and children. The trust target for compliance with safeguarding training was 90%. Training compliance with all levels of safeguarding adults and children was 90% and above in most teams. However, compliance was below the trust target in:

Level 3 safeguarding children:

• Crombie CMHT (Bedfordshire) - 80%
• Beacon CMHT (Bedfordshire) - 73%
• Early Intervention Service (Bedfordshire) - 86%
• Bedfordshire Recovery Team – 85%
• Spring House CMHT (Bedfordshire) - 83%
• City and Hackney Neighbourhood Recovery Service – 83%
• EQUIP Team (Early Intervention City Hackney) - 84%
• City and Hackney North CMHT – 82%
• City and Hackney South CMHT – 71%
• Community Recovery Team North (Newham) - 83%
• Isle of Dogs Neighbourhood Mental Health Team – 71%

Level 2 safeguarding children:

• Bedford North CMHT – 86%
• Community Integrated Mental Health Team (South) - 80%
• Community Integrated Mental Health Team (North) - 83%
• Bow Poplar Neighbourhood Mental Health Team – 67%
• Bethnal Green Neighbourhood Mental Health Team – 83%

Level 1 safeguarding children:

• Meadow Lodge CMHT (Bedfordshire) - 50%
• Luton Community Mental Health Hub – South – 67%

Level 3 safeguarding adults:

• Crombie CMHT (Bedfordshire) - 60%
• Beacon CMHT (Bedfordshire – 82%
• Early Intervention Service (Bedfordshire) - 76%
• Bedfordshire Recovery Team – 80%
• Spring House CMHT (Bedfordshire) - 75%
• Meadow Lodge CMHT (Bedfordshire) - 80%
• City and Hackney Neighbourhood Recovery Service – 83%
• EQUIP Team (Early Intervention City Hackney) - 81%
• City and Hackney North CMHT – 82%
• City and Hackney South CMHT – 57%
• Community Integrated Mental Health Team (North) - 86%
• Isle of Dogs Neighbourhood Mental Health Team – 78%

Level 2 safeguarding adults:

• Spring House CMHT (Bedfordshire) - 67%
• City and Hackney North CMHT – 80%
• Luton Community Mental Health Hub – South – 73%
• Bow Poplar Neighbourhood Mental Health Team – 67%
• Bethnal Green Neighbourhood Mental Health Team – 75%

Following our inspection, the service provided information showing compliance had improved across all teams. However 13 teams were still below the trust target of 90%. The service told us they were monitoring teams where compliance is below this, and non-complaint staff were prioritised to be booked onto training.

Staff could give examples of how to protect people from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff were aware that many people using their services were vulnerable to abuse through domestic violence, coercive control or exploitation. Staff gave examples of when they had made safeguarding referrals, such as when someone would disclose financial abuse. Staff reported specific concerns through the safeguarding process.

The trust-wide policy set out the requirements for safeguarding supervision for staff, which was additional to clinical and managerial supervision. This took place 4 times a year. The policy 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 service provided information that showed 117 safeguarding alerts were made to local authorities in October 2025. Between November 2024 and October 2025 the highest number of alerts made to local authorities were regarding emotional abuse (504 alerts), and physical abuse (380 alerts). However, this information was for all of the adult mental health directorate and not specific to these services.

Staff knew how to identify people at risk of, or suffering, significant harm. They knew where to access information on how to raise safeguarding concerns. Staff gave examples of raising safeguarding alerts such as when they recognised potential domestic violence and concerns about children in the house. Staff told us they received feedback from safeguarding alerts they raised.

Senior staff attended the local safeguarding adults boards in each local authority area. Staff worked in partnership with other agencies to safeguard people. For example, they told us about working with the local authority safeguarding team, the police and housing officers to support a vulnerable person.

The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to people who used services and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. However, this was not always documented.

Staff carried out comprehensive assessments of people who used their services’ mental and physical health needs. They showed people were involved in their risk management plan with their views highlighted in line with their care plan. We reviewed 30 care records across the community-based mental health services for adults of working age service. Of these, 22 of the 30 records showed risk assessments were completed and updated regularly and appropriate risk management plans put in place. Of the other 8 care records, 7 care records had not been updated regularly, or not within the correct part of the care record. One care record had referral notes but no initial risk assessment.

Staff could recognise when to develop and use crisis plans and advanced decisions according to people’s need. Staff involved people in care planning and risk assessment. Records showed that care plans and risk assessments had been discussed with the person using the service. People told us that staff had discussed risks with them in an open and honest manner.

Staff responded promptly to any sudden deterioration in someone’s health. In each team, nurses were allocated to the duty desk. Staff monitored people on waiting lists for changes in their level of risk and responded when risk increased. This meant that staff had a good understanding of the risks presented by people who were waiting for an intervention.

Staff met regularly to discuss individuals' risks. We reviewed minutes and logs of multidisciplinary team (MDT) meetings and complex case discussions where individuals were discussed. We saw staff discussed people’s current presentation and symptoms, any concerns and risks and made appropriate plans to address the risks.

However, during our inspection, we found though risk assessments were mostly completed, the service did not have a consistent process to audit the completion and quality of risk assessments and risk management or safety plans. We requested audits conducted on risk assessments and risk management plans and the service provided a number of different documents for each borough. The trust did provide audit results for the overall localities, but it was unclear which results were for the adult community mental health service.

Following our inspection the trust told us that they were introducing a standardised review of care records audit process across all adult community mental health teams. Team managers would review care records monthly, to be overseen by operational leads and deputy director. They told us the trust is also working towards moving all clinical audits onto the incident reporting system so there would be centralised oversight. The trust also planned to introduce a new electronic risk assessment form to provided further standardisation. The trust would be providing training on the new audit process and care records formulation form.

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

Staff did regular risk assessments of the care environment. Reception staff were aware when higher risk people were coming to the building. Rooms used by the teams were secure, and rooms where staff saw people who used the service had access to alarms.

All areas were clean, well maintained, well-furnished and fit for purpose. Staff were friendly and welcoming. Clinic rooms were clean and well organised, with secure medicines storage.

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

The service had vacancies across their staff group. In October 2025, the service had vacancies for band 6 nurses across all localities. In Bedfordshire and Luton, there were 11.1 Whole Time Equivalent (WTE) vacancies. In City and Hackney, there were 14.3 WTE vacancies, in Newham, there were 2.2 WTE vacancies. In Tower Hamlets, there were 11.1 WTE vacancies.

There were vacancies for healthcare assistants across all localities. In Bedfordshire and Luton there were 8 WTE vacancies. In City and Hackney, there were 8.7 WTE vacancies, in Newham there were 4.4 WTE vacancies, in Tower Hamlets there were 2 WTE healthcare assistant vacancies.

In some teams, the service would mitigate the impact of vacancies by providing additional staff in other roles. For example, in Tower Hamlets, teams had additional Band 5 or Band 7 nurses that were not within the staffing establishment. Establishment numbers are the number of staff the trust or service has calculated it needs. However, staff told us that they felt increased pressure due to a rise in referrals and vacancies within the teams.

Following our inspection the trust provided information that showed an improvement to the vacancy rates across most community mental health teams. In Bedford, there were 17.49 Whole Time Equivalent (WTE) vacancies. In City and Hackney, there were 1.1 WTE vacancies, in Tower Hamlets, there were 3.2 WTE vacancies, and in Luton there were 6.35 WTE. Bedford was supported by 13.59 WTE temporary staffing, and achieved a substantive workforce fill rate of 80.9%.

There were low turnover rates across the service.

The overall trust sickness absence rate between November 2024 and October 2025 was 5.3%. The service had sickness absence rates higher than this rate across all localities. In Bedfordshire, the sickness absence rate was 15.09% for Crombie community mental health team (CMHT), 7.26% for Meadow Lodge CMHT, 6.4% for Spring House CMHT, 5.18% for Beacon CMHT, 5.65% for the Recovery team and 6.12% for the Early Intervention service. In Luton, the sickness rate was 8.24% for the South Community Mental Health Hub. In City and Hackney, sickness absence rates were 7.27% for the Neighbourhood teams and 7.01% for the South CMHT. In Newham the sickness absence rate was 6.71% for the South Community Integrated Mental Health team. In Tower Hamlets, the sickness absence rates were 12.23% for Bethnal Green CMHT, 6.63% for Stepney and Wapping CMHT.

Following our inspection the trust provided information that showed a number of teams had lower rates now. The trust told us these rates were due to a small number of long-term sickness cases and provided rolling 12 month sickness rates for clarity. Additionally the trust told us some of these were small teams were a few absences can have a greater impact. The trust managed sickness in line with the trust’s sickness absence policy, and reviewed absences to identify themes so trust could implement actions to address these causes.

As of July 2026 in Bedfordshire, the sickness absence rate was now 16.57% and rolling 12-month sickness absence rate was 6.39% for Crombie community mental health team (CMHT), 7.39% and rolling 12-month sickness absence rate was 6.92 for Beacon CMHT, 14% and rolling 12-month sickness absence rate was 3.99% for the Recovery team and 7.92% for the Early Intervention service. In Luton, the sickness rate was 4.86% for the South Community Mental Health Hub. In City and Hackney, sickness absence rates were 0.5% and rolling 12-month sickness absence rate was 3.04% for the Neighbourhood teams and 1.38% for the South CMHT. In Newham the sickness absence rate was 2.99% and rolling 12-month sickness absence rate was 2.31% for the South Community Integrated Mental Health team. In Tower Hamlets, the sickness absence rates were 6.90% for Bethnal Green CMHT, 10.46% for Stepney and Wapping CMHT.

Managers mostly deployed agency and bank nursing staff when necessary to maintain safe staffing levels. We reviewed data for August to October 2025 which showed low numbers of unfilled bank and agency shifts in teams across all localities.

Managers gave all new staff, including bank and agency staff a local induction.

The trust had an up-to-date policy on learning and development which outlined the statutory and mandatory training requirements for staff. Most staff completed mandatory training. Managers monitored their team’s compliance against a trust target for mandatory training of 90%. Though not all teams met the 90% target, compliance with mandatory training was close to this in most subject areas. Where compliance was lower, this was usually due to small team sizes and 1 staff member not being complaint.

In the Bedfordshire and Luton locality where there were the large, medium and small teams, there were 158 courses under the trust target of 90% with the lowest ones being 53% for fire safety in large teams, 60% for adult basic life support in the medium teams, and 0% for breakaway training in the small teams.

In the City and Hackney locality where there were the large, medium and small teams, there were 51 courses under the trust target of 90% with the lowest ones being 70% for adult basic life support in large teams, 75% for fire safety in the medium teams, and 0% for breakaway training in the small teams.

In the Newham locality where there were the large, medium and small teams, there were 35 courses under the trust target of 90% with the lowest ones being 47% for breakaway training in large teams, 67% for adult basic life support in the medium teams, and 0% for adult basic life support in the small teams.

In the Tower Hamlets locality where there were the large, medium and small teams, there were 30 courses under the trust target of 90% with the lowest ones being 50% for breakaway training in large teams, 55% for safe administration of medicines in the medium teams, and 50% for patient handling training in the small teams.

Following our inspection the trust told us that training was being monitored at trust, directorate, service team and individual level. Managers attended monthly performance and governance meetings where training, supervision and appraisal data was reviewed. The trust used the dashboard to identify gaps in training, and reminders were sent to non-compliant staff, and this was discussed in staff supervision. The service was working on ensuring completed training was being recorded accurately, including piloting QR code attendance so that training was recorded directly to the system.

The trust had an up-to-date supervision policy which outlined the requirements for managerial supervision and clinical and professional supervision for all staff. However, not all staff received managerial and clinical supervision. In Bedfordshire compliance with managerial supervision was 49% and clinical supervision was 50%. In City and Hackney compliance with managerial supervision was 21% and clinical supervision was 22%. In Luton compliance with managerial supervision was 28% and clinical supervision was 23%. In Newham compliance with managerial supervision was 52% and clinical supervision was 46%. In Tower Hamlets compliance with managerial supervision was 43% and clinical supervision was 40%.

In the Tower Hamlets directorate, the service provided a supervision and training action plan to improve mandatory training and supervision compliance in the community and crisis mental health teams. The aim was to improve compliance to above the trust target of 90% within 2 months of our inspection. They did not provide a similar plan for other directorates.

Following our inspection the trust provided information that showed compliance had improved across the service. In Bedfordshire compliance with managerial supervision was 78% and clinical supervision was 79%. In City and Hackney compliance with managerial supervision was now 62% and clinical supervision was now 68%. In Luton compliance with managerial supervision was now 83% and clinical supervision was now 87%. In Newham compliance with managerial supervision was now 84% and clinical supervision was now 77%. In Tower Hamlets compliance with managerial supervision was now 84% and clinical supervision was now 82%. However all teams were still below the trust target of 90%.

The service had a lone working policy and arrangements for staff in place. However, this was not applied consistently to all staff. All visits to people who used the service were risk assessed, and if a person were unknown to the service or assessed as being high risk, then 2 staff members would attend the appointment together. There were sign in and out sheets at reception. There was a process in place for staff to be able to alert the service that there was increased risk and they needed assistance. If a home visit went past 5pm staff were asked to call the staff member on duty. The service also provided a phone application for staff to use in an emergency, however the trust did not have enough licenses so that all staff could have this application.

Following our inspection the trust provided information that after the inspection the trust ran a trust wide review of lone working phone application registrations. As of June 2026 97% of registered users of the application had activated and were using the system. The trust told us there was a revised lone working policy is being progressed through the trust's formal approval process. The revised policy is intended to provide clearer and more consistent minimum standards for lone working, including use of lone worker technology, local check-in and escalation arrangements and management oversight.

Not all staff received an annual appraisal. The trust changed the appraisal system in February 2025. At the end of November 2025 trust-wide appraisal compliance was 44%. The trust did not provide this information specific to community-based mental health services for adults of working age to show the overall service compliance. The service provided information that showed in Bedfordshire 50% of staff had received an appraisal. In City and Hackney, 23% of staff had received an appraisal. In Luton, 19% of staff had received an appraisal. In Newham, 47% of staff had received an appraisal. In Tower Hamlets, 50% of staff had received an appraisal. The trust had an action plan to improve their appraisal compliance rate.

Following our inspection the trust provided information specific to community-based mental health services for adults of working age that showed compliance had improved across the service. In Bedfordshire 86% of staff had now received an appraisal. In City and Hackney, 70% of staff had now received an appraisal. In Luton, 95% of staff had now received an appraisal. In Newham, 90% of staff had now received an appraisal. In Tower Hamlets, 90% of staff had now received an appraisal.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff had completed infection prevention and control training.

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

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

Staff adhered to infection control principles and washed their hands before giving care and treatment such as injections.

Staff received level 1 and 2 training in infection prevention and control. The trust target for this was 90%. Compliance across the localities was Bedfordshire at 77%, City and Hackney at 84%, Luton at 81%, Newham at 89% and Tower Hamlets at 96%. Following our inspection, the service provided information showing compliance had improved so that all teams were now above the trust target. Bedfordshire was now at 92%, City and Hackney was now at 95%, Luton was now at 96%, Newham was now at 92% and Tower Hamlets was now at 95%.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. There were gaps in oversight of medicines that the service had identified prior to the inspections and were already actively working to improve. However, the service made sure to involve people in planning, including when changes happened.

The service had some systems and processes in place to support the safe and effective use of medicines in community mental health settings. Pharmacy support was embedded across most teams and contributed positively to medicines reconciliation, patient education, and continuity of care. Staff demonstrated proactive approaches to engaging patients at risk of non-adherence, including home visits and escalation through multidisciplinary team (MDT) meetings.

Clozapine (a medicine requiring strict blood monitoring) and depot (long-acting antipsychotic injection) clinics were well-managed, with clear processes for medication administration and physical health monitoring in line with national guidance. However, the provider had recognised gaps in oversight of other medicines requiring additional monitoring. There was no robust system to provide assurance that all checks were carried out consistently. However, we reviewed 34 care records relating to medicines and these showed monitoring was being completed. The service had initiated several quality improvement projects to address these gaps, including work to develop centralised tracking tools and improved audit processes. These projects were in progress but had not yet been fully implemented at the time of inspection. Following our inspection the trust told us that they planned to discuss implementing a standardized Trust-wide approach to side effect monitoring, alongside raising awareness among staff of the importance of structured side effect monitoring and the use of recognized tools. The trust told us by February 2026 the use of side effect rating scales will be incorporated into the quarterly clinical use of medicines audit.

Documentation of side effect monitoring lacked consistency, with limited use of recognised tools such as the Glasgow Antipsychotic Side Effect Scale (GASS). Staff were aware of this and had plans to standardise the use of rating scales as part of their QI work. Capacity and consent were generally recorded, but some records lacked sufficient detail to demonstrate compliance with Mental Capacity Act requirements. Following our inspection the trust told us they planned to introduce a performance measure for community mental health teams of capacity and consent recordings done alongside community treatment orders, to ensure they contain enough detail comply with Mental Capacity Act requirements.

Medicines governance arrangements were not robust. The service used prescription pads and these were securely stored in most locations, however there was no clear audit trail or oversight in some teams. Stock management in depot clinics was not always inconsistent. We found examples of overstocking and out-of-date medicines. Temperature monitoring was not always completed consistently, and actions were not documented when ambient temperatures exceeded recommended limits. The service was undertaking actions to make improvements. The pharmacy team were completing audits for the service with actions for improvement. A fridge that monitored temperatures had been purchase for the Newham community integrated mental health team (South).

Following our inspection the trust provided information that they increase the number of electronic prescribing system licenses available to prescribers so they could move away from paper prescription They were also planning to they had amended their prescription pad policy to ensure better recording. This process was audited and helped identify gaps in managerial oversight and record keeping. The results of the audit were to be discussed at the medicines committee in November 2026.

The trust also told us would be moving from community depot stock provided by an external provider, to being managed within the trust. This would give the service better oversight of medicine stock, and this was due to be completed by end of March 2026.

Physical health monitoring for people prescribed psychotropic medicines was not always comprehensive. While some teams maintained spreadsheets and used portable equipment to complete checks, audits indicated gaps in annual health checks and cardiometabolic monitoring. The service had acknowledged these gaps and was working to strengthen oversight through new processes and collaborative work with primary care networks. Following our inspection the trust told us they had approved and begun implementing a trust-wide core standards and expectations for physical health monitoring and management in community mental health services. This framework would provide a consistent framework and set out the physical health monitoring offer. The trust had also reviewed physical health equipment across community services and were developing a dedicated community physical health dashboard to provide greater visibility of completed and outstanding monitoring, to be implemented by the end of September 2026.

However, there were numerous examples of good practice. Pharmacy teams were actively involved in MDT meetings, triage processes, and patient-facing clinics. Staff provided medicines information in accessible formats, including translated and easy-read leaflets. Collaborative working with GP`s, primary care networks and community pharmacists supported shared care arrangements. Incident reporting and learning were embedded, and audits of clinical use of medicines and safe storage were being completed, with actions in place.

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