East London NHS Foundation Trust

On this page

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

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last inspection we rated this key question good. At this inspection the rating has changed to requires improvement.

We found 1 breach of regulations in relation to consent and use of the Mental Health Act.The score of 1 for the quality statement delivering evidence-based care and treatment limits the overall key question rating to requires improvement.

Requires Improvement: This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

Staff did not always understand their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and did not consistently discharge these well. The service did not always tell people about their rights under the Mental Health Act.

However, staff assessed the physical and mental health of all people who used services on referral and acceptance to the service. Staff provided a range of treatment and care for people based on national guidance and best practice. Staff from different disciplines worked together as a team to benefit patients.

This service scored 58 (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 mostly made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

During our inspection, we reviewed 21 care records of people who used crisis services and 9 records of patients using health-based places of safety (HBPoS). We found they contained timely and comprehensive notes. However, we found inconsistencies in how staff recorded care plans and risk assessments on the electronic care record system. Staff did not always use templates within the care record system, with information often recorded within progress notes. This meant important information about a person’s needs or risk could be difficult to find within the care record.

Staff did not consistently use alerts within the care record system to highlight a person’s needs or risk. For example, we saw a vulnerable person alert was used on some records, however we saw another record where a person’s history indicating a potential safeguarding concern did not have an alert on the care record.

In records we reviewed in Luton and Bedfordshire we found people were involved in creating their safety plans and got copies of these.

Records showed staff completed a comprehensive mental health assessment of people who used services in a timely manner at, or soon after, referral to the team. This included a joint assessment with other teams, where appropriate.

Staff assessed people’s physical health needs in a timely manner. Records showed physical health assessments were completed soon after a person’s referral to the team.

The service did not always provide care and treatment in line with legislation. Staff did not always follow their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice nor discharge these well. However, care and treatment was provided in line with current evidence-based good practice and standards. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them.

The service did not always ensure care and treatment delivered under the Mental Health Act (MHA) was provided in line with legal requirements.

In Luton HBPoS, records showed some patients remained beyond the 24-hour period of detention permitted under section 136 of the MHA. The service provided data showing between November 2024 and October 2025 most patients (328 out of 358) stayed in the HBPoS less than 24-hours. However, this did not match the admission spreadsheet we reviewed during our inspection in which more patients were detained for 36 to 72 hours than were accounted for, and 12 patients were missing relevant data. Therefore, the lawful authority for detaining people beyond 24 hours was not always clear.

Following our inspection, the service provided further information showing the discrepancy between data and the admission spreadsheet seen on site was due to differences in online and manual data tracking tools used. The service completed a manual audit of all 358 patients who stayed in Luton HBPoS between November 2024 and October 2025. They found 29 patients who were detained under a section 136 of the MHA who stayed longer than 24 hours on the HBPoS. Of these, 10 stayed 24 to 26 hours, 7 over 36 hours and 1 over 72 hours. They identified missing data entries for 12 patients, of which 5 patients stayed in the HBPoS longer than 24 hours. They told us they had reviewed individual patient records for anyone appearing to breach the 24-hour period. The trust made changes to the bed management strategy to ensure patients assessed as requiring a bed were prioritised for transfer to a ward.

The service did not have robust processes to ensure it only discharged its duties under the MHA to the correct people. The service informed us of an incident in April 2025 where the incorrect person was detained under the MHA and admitted to Luton HBPoS. The person showed identification but checking this was not a requirement on admission. The person was then admitted to an inpatient unit for 7 hours before discharge.

Following our inspection, the service updated documentation standards and the admission checklist to include identity checks on arrival, verification of MHA paperwork, and confirmation of legal status. They revised protocols to require immediate demographic checks and rapid escalation of any discrepancies to the senior nurse, MHA Office, and on‑call manager.

We found patients admitted to Luton health-based place of safety (HBPoS) did not consistently receive accurate information about their detention and rights.

We spoke to patients who had been admitted to the Luton HBPoS who told us they did not know what section they had been detained under, and nobody had explained why they had been detained. Some said staff had not spoken to them and had not given them any written information.

One patient showed us the sheet staff had given them about section 136. Staff had not filled in any relevant information such as nearest relative, date and time the section started, or date and time of the section would have ended. Additionally, they said they been transferred from the emergency department (ED) so the time their detention under section 136 started was unclear. Staff had recorded the patient “was informed about rights” but written nothing for “level of understanding”.

Following our inspection, the service told us they had delivered training to all HBPoS staff on ensuring that the s132 explanation of rights leaflet was completed consistently and patient rights documentation updated to guarantee that the start and end times of detention were clearly documented and provided to every patient upon arrival. They included reading of rights under section 132 as a standing agenda item on monthly clinical supervision. The service planned to deliver additional training in April 2026 on people’s legal rights when detained under a section 136 including techniques for explaining rights in a clear and accessible way. The audit in May 2026 showed 100% compliance with sharing the rights leaflet with patients.

Most staff received training in the MHA. However, compliance varied between 40% and 100% across crisis teams, against a trust target of 90%. Compliance was below the trust target in:

• Bedford 111 service at 40% (2 out of 5 staff)
• City and Hackney crisis line at 78% (7 out of 9 staff)
• City and Hackney Home Treatment Team (HTT) at 73% (8 out of 11 staff)
• City and Hackney Homerton psychological medicine team at 57% (8 out of 14 staff)
• Tower Hamlets HTT at 77% (10 out of 13 staff)

Following our inspection, the service provided updated training compliance figures for June 2026 showing compliance was:

• Bedford 11 service 100%
• City and Hackney crisis line 100%
• City and Hackney HTT 100%
• Homerton psychological medicine team 92%
• Tower Hamlets HTT 93%

Not all teams had peer support workers. For example, the service sent information that showed Tower Hamlets Home Treatment Team did not employ a peer support worker, nor did Bedfordshire or Luton Crisis Resolution Home Treatment teams. The service told us it was difficult to give an exact number of peer support workers employed, due to inconsistencies in how roles were recorded across the trust. A peer support worker is a mental health professional who uses their own lived experience of mental distress to support others on their recovery journey.

However, in home treatment and crisis assessment teams, staff provided a range of care and treatment interventions suitable for people using services. The interventions were those recommended by, and were delivered in line with, guidance from the National Institute for Health and Care Excellence. For example, City and Hackney Crisis Assessment Team (CAT) provided rapid same-day assessments for people experiencing an acute mental health crisis. They provided a complex emotional needs clinic for people who might not be suitable for home treatment or therapy services. People attended an appointment with a practitioner trained in structured clinical management every 2 weeks for 3 sessions. This aimed to stabilise them enough to be able to engage with mentalisation-based therapy (MBT) in the community. MBT is an evidence based psychological therapy originally for emotionally unstable or borderline personality disorders but has been developed for other complex emotional needs.

The service developed a new risk assessment form in November 2025. This was developed by clinicians and the people participation team in line with NHS England guidance, ‘Staying safe from suicide – best practice guidance for safety assessment, formulation and management’. This was being implemented across the trust at the time of our assessment, with training and further roll out planned in early 2026.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff held regular multidisciplinary team (MDT) meetings. We reviewed minutes of MDT meetings in City and Hackney and Newham Home Treatment Teams (HTT) and saw individuals were discussed by the team and plans made.Staff recorded discussions at MDT meetings in individual care records.

During our inspection, we attended MDT meetings and huddles in Newham and Luton and Bedfordshire localities. We found they were attended by all relevant staff and there was robust clinical discussion and constructive challenge in most meetings we observed.

Staff in all 4 localities attended regular business meetings. Though agendas differed across different teams, minutes we reviewed showed all teams discussed performance against key performance indicators such as referrals, audits of care records, mandatory training compliance and complaints.

The service had effective working relationships with other relevant teams within the organisation. For example, in Luton and Bedford managers attended monthly interface meetings with addictions and child and adolescent mental health services (CAMHS) teams and the local acute NHS trust to manage any pathway issues, escalate them and coordinate responses across the services.

The service had effective working relationships with teams outside the organisation. For example, in Luton and Bedford, managers were part of the NHS confederation collaborative work to improve pathways and joint working between crisis services and the local acute NHS trust. In London, managers attended the North East London crisis improvement network meeting. This meeting brought together partners from across the system to coordinate projects covering accident and emergency department mental health care, psychiatric liaison services, health-based places of safety, joint response models, digital tools, and crisis-alternative services to improve crisis pathways.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff supported people to live healthier lives. We saw physical health, lifestyle and wellbeing needs reflected in people’s care records we reviewed. During MDT discussions staff considered the impact of unhealthy lifestyles on people. For example, we saw staff discussing how they could promote good sleep hygiene for someone.

Some teams included occupational therapists who supported people to build skills to maximise their independence.

Staff supported people to take part in activities that promoted a healthy lifestyle. For example, Newham Home Treatment Team (HTT) ran groups such as gardening, movement and music therapy which people could access during their time with the team and for a short period after discharge. In bases used by crisis teams we saw leaflets and posters promoting healthy activities and groups to support people with their wellbeing and physical health.

The service routinely monitored people’s care and treatment to continuously improve it.

In Bedfordshire and Luton locality, managers and lead clinicians carried out regular quality audits of care records. They used the outcomes from the audit to highlight areas for improvement. For example, they planned additional training from pharmacy staff in response to the audit outcomes.

In Newham locality, managers used an online tool to carry out audits of care records. Audit results were shared with staff by email and in business meetings. Actions following audits included reminding staff to complete online risk assessments in the electronic care record at each assessment and when new risks emerged.

The service told people about their rights around consent or respect these when delivering care and treatment. However, staff did not always complete training around this.

However, staff assessed and recorded capacity to consent appropriately when it was suspected a patient’s mental capacity was impaired. Capacity to consent was considered at each assessment and recorded in the care records we reviewed. This included consent to share information with family and carers, where appropriate.

Patients we spoke to in the HBPoS were aware of their right to an Independent Mental Health Advocate (IMHA). We saw posters for advocacy services displayed in bases we visited.

Staff mostly received training in the Mental Capacity Act (MCA). Data provided by the service showed compliance was above the trust target of 90% in all teams in Bedfordshire and Tower Hamlets. However, compliance was below the trust target in:

• City and Hackney crisis line at 80%
• City and Hackney HTT at 87%
• Homerton Psychological Medicine team at 59%.
• Luton medical staff at 67%
• Luton street triage at 0% (though only 1 member of staff was eligible)
• Newham HTT at 85%

Following our inspection the service provided information showing compliance had improved in June 2026 to:

• 88% at City and Hackney crisis line
• 100% at City and Hackney HTT
• 75% at Homerton Psychological Medicine team
• 89% for Luton medical staff
• 91% at Newham HTT