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, safe environments, including at the health-based places of safety and the deployment of sufficient staff.

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.

Staff did not always 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.

However, the service mostly ensured lessons were learnt from safety incidents. Staff acted to safeguard people using services, sharing concerns quickly and appropriately. The service mostly worked well with people to understand and manage risks. Most staff completed mandatory training and received supervisions and appraisals. 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 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

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 292 incidents between September and November 2025, of which 234 were categorised as LFPSE and 58 as non-LFPSE. However, we reviewed incidents the service had categorised as non-LFPSE and found 18 incidents which could potentially have met the LFPSE definition of a patient safety event. This meant we could not be assured the service consistently recognised nor 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 not taken.

Following our inspection, the trust told us the patient safety team reviewed the 58 non-LFPSE incidents and identified some where the categorisation was not clear. These mainly related to the completion of Mental Health Act paperwork and safeguarding relating to other members of the person’s family. The trust told us they would introduce strengthened guidance on reporting such incidents as patient safety or non-patient safety by the end of July 2026.

The service reported 7 patient safety incidents categorised as severe harm or death between December 2024 and November 2025. Of these, 6 incidents related to the death of someone using crisis services and the other to an assault on a member of the public by someone who was using crisis services. A patient safety incident investigation (PSII) was conducted for all these incidents.

We reviewed the PSII reports for 3 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 was 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, 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 Bedford crisis resolution home treatment team (CRHT) told us about new trust guidance on working with private providers, which had been developed following learning from an incident. Some staff told us they planned to discuss the learning and review the guidance as a team at their next team meeting.

The service had no never events in the last 12 months. Never events are defined as wholly preventable patient safety events.

The service did not receive any prevention of future deaths reports in the last 12 months. 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.

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 9 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 mostly 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. However, staff did not always follow clear processes for people who disengaged from services.

The process for staff to follow for people who did not attend appointments or who disengaged from services was not clear. During our inspection, different staff described different processes to us. For example, some staff told us people would be discharged if they missed 3 appointments, others told us a decision to discharge following non-attendance was made on an individual basis. The trust website stated each service had an individual DNA policy in line with the framework set by local commissioners. However, the trust-wide waiting times and access policy outlined the trust approach to DNA and set a standard for this for adult mental health services. We reviewed trust board papers from September 2025 and saw the trust had implemented a quality improvement project which included implementing training for staff on the DNA policy but staff were not able to clearly describe this during our inspection. The service did not provide evidence they audited or monitored compliance with DNA policies and processes.

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 policy in Newham locality was under review. The trust had a group looking at developing a standardised approach to people who may need an assertive approach.

We requested the trust’s policy, process and any audits in relation to the use of Right Care, Right Person. Right Care, Right Person is an agreement between policing, health and other relevant partners that sets out the principles around the Right Care, Right Person approach which aims to ensure that individuals in mental health crisis are seen by the right professional. The service told us Right Care, Right Person (RCRP) was embedded across the trust’s police liaison governance structures. Staff in each borough met regularly with the police in local police liaison meetings. Staff escalated concerns to the trust Senior Police Liaison Group if there was a pattern of inappropriate police demand, local resolution was not possible, issues required police senior leadership involvement or themes affected more than one borough.

In City and Hackney locality, a dedicated pathway manager ensured transitions between psychiatric liaison services, the street triage team, crisis assessment team and home treatment team (HTT) were managed effectively.

Staff in City and Hackney HTT supported people who were discharged from hospital into ‘step down’ beds provided by an external agency. Mental health step-down beds provide short-term, supported accommodation for people clinically ready to leave acute hospital care but who require further monitoring before living independently.

Staff involved all the necessary healthcare and social care services to ensure people who used services had continuity of safe care. For example, managers in Newham HTT met daily with psychiatric liaison services to share information about people being discharged from accident and emergency departments to HTT support.

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 in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

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 for level 3 safeguarding children in:

• Bedford AE Liaison and CRHT at 82%
• Bedford 111 service at 80%
• City and Hackney Home Treatment Team (HTT) at 81%
• City and Hackney Homerton psychological medicine team at 79%
• Luton crisis medical staff at 88%
• Tower Hamlets HTT at 85%

Following our inspection, the service provided information showing in all these teams compliance had improved or staff who had not completed the training were booked onto upcoming training. In Tower Hamlets crisis line, compliance with level 1 safeguarding children training was 50% but this was 1 out of 2 eligible staff and due to sickness absence. Compliance was below the trust target for safeguarding adults level 3 training in:

• City and Hackney HTT at 81%
• City and Hackney Homerton psychological medicine team at 84%
• Newham HTT at 85%
• Luton crisis psychology team at 67% (2 out of 3 eligible staff)
• Luton crisis medical staff at 75% (6 out of 8 eligible staff)

Following our inspection, the service provided information showing compliance at Newham HTT had improved to 96% and staff at the City and Hackney teams were booked onto upcoming training.

Staff received safeguarding supervision from trust safeguarding leads, with 313 supervision sessions held between April 2025 and March 2026.

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 this service.

Senior staff attended local safeguarding adults boards in each local authority area.

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.

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 mostly worked well with people to understand and manage risks. They mostly provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments were completed in 17 out of 21 care records we reviewed. Where completed, these were comprehensive and evidenced the person’s involvement.

However, staff did not always update people’s risk management plans on discharge from the service. We reviewed 10 care records for people recently discharged from crisis teams and saw the risk management plan was only updated in 3 people’s records.

Though 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. For example, in City and Hackney they provided information for weekly HTT caseload audits which showed if a risk assessment had been completed and when it was last updated. The service told us in Newham this was included in the directorate-wide audit conducted 3 times each year. In Bedfordshire and Luton, the information on risk assessment and safety plan dates was within the caseload contact times audit. In Tower Hamlets 111 option 2 service the quality of risk assessments was looked at as part of the audit of calls to the phone line. At Tower Hamlets HTT risk was discussed at the management meeting.

Where audits were carried out, they showed risk assessments were being completed by staff. Following our inspection, the service told us a new risk assessment and formulation form would be rolled out on the electronic patient record system throughout 2026 and would include plans for monitoring and audits of its use.

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, the service did not provide evidence that these meetings took place in every locality. For example, for Luton Crisis Resolution Home Treatment (CRHT) team the service provided minutes of the team meeting, which was not an MDT meeting. They did not provide minutes of MDT meetings in Tower Hamlets.

The service monitored incidents of restrictive practice. We reviewed incidents where restrictive practice was used between May and November 2025. Details of incidents of restrictive practice provided by the trust included the place the incident took place.

There were 14 incidents of seclusion between May and November 2025, of which 1 incident was within an emergency department (ED), 7 within City and Hackney HBPoS and 5 in Luton HBPoS. There were 25 incidents of rapid tranquilisation of which 1 was within an ED, 12 within City and Hackney HBPoS, 7 within Luton HBPoS, 1 within Newham HBPoS, 2 at Newham psychiatric liaison service and 2 at Tower Hamlets psychiatric liaison service. There were 40 incidents of holding restraint, 1 of which was within an ED, 1 in the street triage team, 1 in City and Hackney crisis assessment team, 18 in City and Hackney HBPoS, 16 in Luton HBPoS, 1 in Newham HBPoS, 1 in Newham crisis assessment team and 1 in Tower Hamlets psychiatric liaison service. There were 4 incidents of segregation of which 1 was within an ED, 2 at Luton HBPoS and 1 at Newham CRT.

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

We found concerns with the environment in both HBPoS. Patients in both HBPoS did not have direct access to fresh air.. At City and Hackney HBPoS there was an available area, but this was not used as it was not secure nor fit for purpose, due to equipment and materials in the area which could pose a ligature risk or be used as a weapon. Staff told us they escorted patients to another garden in the hospital grounds or the front of the building if it was safe to do so. However, this was next to a large car park and not contained within the building. Staff told us the responsible clinician considered section 17 as soon as detention under section 2 began. Section 17 of the MHA allows a detained patient to be granted temporary or long-term leave of absence from the HBPoS so this could facilitate access to fresh air.

Following our inspection, the service provided an action plan showing the garden space at City and Hackney HBPoS would be refurbished and available in August 2026. There were no plans to renovate Luton HBPoS but the trust told us it was reviewing options for the future and writing an ‘escorted fresh air access protocol’

The Luton HBPoS did not have a clock visible to patients. Patients may not have known the time their detention should have ended without a personal clock or phone. Following our inspection, the service confirmed they had installed a wall-mounted clock which could be seen from all patient areas.

One room in the City and Hackney HBPoS had a blind spot for the CCTV, which meant staff could not see the bathroom. We were informed this was due to an issue with the connection and had been escalated. However, staff told us this had been an issue for 2 years. Staff told us they mitigated the risk by regular observations that included the blind spot. They could use a panel to view the bathroom without entering the room. Following our inspection, the service told us issues with connectivity were being investigated by the CCTV supplier.

At Luton HBPoS the CCTV feed was displayed on a monitor in the observation room. The view included the corridor outside the bedroom, the bedroom, and the swing door into the bathroom. The toilet was entirely visible if the bathroom swing door was open. Following our inspection, the service confirmed CCTV was no longer live streamed or used as a clinical observation tool, staff were reminded about privacy standards and appropriate use of CCTV.

We spoke with 2 patients who told us whilst aware they were being recorded by CCTV, did not realise it was viewable live, nor that staff working in another ward had access. We could not find information referring to CCTV in the patient welcome pack.

Staff told us they did not monitor the live feed as patients were already nursed on two-to-one as standard. However, it would have been visible to any other member of staff in the observation room. Following our inspection, the service told us they had immediately applied privacy masking to areas of the room and improved signage to explain why CCTV was in use and how privacy would be safeguarded.

The service conducted ligature anchor point audits and assessments for crisis bases which mitigated risks to people who used services. The service told us work was ongoing to apply the ligature risk assessment process used in wards to areas people would access within crisis services. They had a plan to carry out assessments, ensure ligature cutters were available and plan ligature point reduction work by the end of March 2026.

However, at Luton HBPoS, the paper towel and toilet paper dispensers in the bathroom were potential ligature points. Staff told us they mitigated this risk by allowing patients to close the bathroom door but ensuring continual verbal interaction between staff and patients whilst they used the shower or toilet. The ligature points were recorded on a map in the duty senior nursing office. The service conducted a further review of ligature points and identified a risk from the fixtures on paper towel and toilet paper dispensers. The services acted to reduce this risk including dynamic risk assessment, observations and patient specific care planning. Staff were briefed on the ligature audit and required mitigations. Oversight of the risk was through the trust ligature reduction group.

The designated crisis team assessment rooms on the inpatient unit at Newham had press buttons to exit, which could be blocked by someone standing in front of them. The rooms were not ligature free, but staff told us they would never leave a person alone in an assessment room. Following our inspection, the service carried out a joint estates and clinical assessment of the environment. A robust standard operating procedure for the use of the room was put in place to mitigate the risk the position of exit buttons and ligature points posed.

The service carried out environmental health and safety audits regularly at bases used by home treatment teams and crisis teams. We reviewed audits conducted in the last 12 months and saw they were comprehensive and identified any risks along with actions to reduce risk.

The trust had an estates strategy for 2023 to 2028, with an associated action plan and key performance indicators. The strategy acknowledged the estate at Newham was an area of concern and considered a priority.

The service did not always make sure there were enough qualified, skilled and experienced staff. They mostly made sure staff received effective support, supervision and development. Most staff completed mandatory training.

In October 2025, the service had vacancies for band 6 nurses across all localities. In Bedfordshire and Luton, there were 8.2 Whole Time Equivalent (WTE) vacancies. In City and Hackney, there were 1.4 WTE in the crisis line. In Newham, there were 0.3 WTE. In Tower Hamlets, there were 7.6 WTE, of which 4.3 were in the crisis line and 3.3 in the HTT.

There were vacancies for healthcare assistants across all localities. In Bedfordshire there were 6 WTE healthcare assistant vacancies and in Luton there were 5.1 WTE support time recovery worker vacancies. In City and Hackney, there were 2.7 WTE healthcare assistant vacancies. In Newham there were 1.82 WTE healthcare assistant vacancies. In Tower Hamlets there were 5.1 WTE healthcare assistant vacancies in the crisis line team.

In some teams, the impact of vacancies was mitigated by headcount over establishment in other roles. For example, in Bedfordshire Crisis Resolution Home Treatment (CRHT) team there was an additional social worker, band 5 nurse and occupational therapist that were not within the staffing establishment. Establishment numbers are the number of staff the trust or service has calculated it needs.

The service had ongoing recruitment for registered and non-registered posts. In some teams, such as Luton CRHT, vacancies were not recruited to due to service redesign and consultation. In other teams, such as the Tower Hamlets 111 option 2 service vacancies were as a result of service development. The service had contingency plans for when additional staffing was needed to meet clinical priorities including reallocation of existing resources and senior clinician review.

The overall trust sickness absence rate between November 2024 and October 2025 was 5.3%. The service had sickness absence rates higher than the trust rate across all localities. In Bedford, the sickness absence rate was 7.8% for CRHT and psychiatric liaison teams, 9.1% for the 111 option 2 service and 0.9% for medical staff. In Luton, it was 6.1% for medical staff and 5.5% for the CRHT. In City and Hackney, sickness absence rates were 5.9% in the Home Treatment Team (HTT) and 7.6% in the crisis line team. In Newham HTT the sickness absence rate was 6.6%. In Tower Hamlets, the sickness absence rates were 7% in the crisis line and 15.1% in the HTT.

Following our inspection, the service told us the sickness absence rate at Bedford 111 option 2 service had improved to 5.9% by February 2026. There was an ongoing quality improvement project focusing on enhancing staff experience and wellbeing at work. Sickness absence was monitored through deep dive reviews with operational leads, directorate management and human resources staff.

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. However, Luton CRHT had 44 unfilled shifts out of 337 (13%). City and Hackney HTT had 26 unfilled shifts out of 217 (12%).

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 in all subject areas, compliance with mandatory training was close to this in most subject areas except adult basic life support training and safety intervention breakaway training.

In Bedford 111 service compliance with adult basic life support was 50% (3 out of 6 staff). In City and Hackney compliance with adult basic life support was 50% for the health-based place of safety (HBPoS) (2 out of 4 staff), 46% for the crisis line (6 out of 13 staff), 50% for the street triage team (1 of 2 staff) and 63% for Homerton Psychology Medicine team (12 out of 19 staff).

Following our inspection, the service provided updated training compliance figures. These showed compliance with adult basic life support in Bedford 111 service was 62%, compliance at City and Hackney HBPoS had increased to 80%, increased to 82% at the crisis line and 66% for the street triage team and Homerton Psychological Medicine team.

Not all staff completed safety intervention breakaway training. In Bedford 111 service safety intervention breakaway training was 50%. In City and Hackney HTT compliance was 61%. In Newham HTT it was 57% and in Tower Hamlets HTT it was 65%.

Following our inspection, the service provided updated training compliance figures. These showed compliance with breakaway training had increased in Bedford 111 service to 62%, Newham HTT to 59% and Tower Hamlets HTT to 72%. However, compliance at City and Hackney HTT had declined to 47%.

The service told us they had increased capacity for all face to face training such as breakaway and adult basic life support and there was a new booking process for safety interventions training. Compliance was monitored at local level through an online dashboard, with executive level oversight and weekly compliance reports.

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 Bedford CRHT compliance with managerial supervision was 34% and clinical supervision was 38%. In City and Hackney HTT compliance with managerial supervision was 32% and clinical supervision was 27%. In Luton CRHT compliance with managerial supervision was 74% and clinical supervision was 73%. In Newham HTT compliance with managerial supervision was 38% and clinical supervision was 32%. In Tower Hamlets HTT compliance with managerial supervision was 38% and clinical supervision was 32%.

Following our inspection, the service provided evidence showing supervision compliance had improved in all services except City and Hackney HBPoS and street triage teams. The overall compliance rate for crisis services had improved to 74%. However, though it had improved compliance in Tower Hamlets HTT was 67% for managerial supervision and 61% for clinical supervision. The service told us this was due to sickness absence and maternity leave. The trust told us a new digital form to record supervision had been introduced and not all services used this yet which may mean compliance rates recorded centrally by the academy and locally may not align.

For the Tower Hamlets directorate the service provided a supervision and training action plan to improve mandatory training and supervision compliance in community and crisis mental health teams to above the trust target of 90% within 2 months of our inspection. They did not provide a similar plan for other directorates. However, the service told us all localities had action plans to improve supervision compliance rates.

Most staff received an annual appraisal. The trust changed the appraisal system in September 2025. At the end of November 2025 across all crisis teams appraisal compliance was 61%. Following our inspection, the appraisal compliance improved to 89% in June 2026.

There were low turnover rates across the service.

The service mostly assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service had appropriate policies and guidance for staff to follow in relation to preventing and controlling infections.

The service carried out annual health, safety and security inspections in City and Hackney which included an inspection of cleaning carried out and storage of sharps and substances hazardous to health. We reviewed the annual inspection for July 2025 and saw no issues had been identified in relation to infection prevention and control. Staff at City and Hackney health-based place of safety (HBPoS) carried out a weekly environmental audit including availability of hand sanitiser, completion of cleaning schedules, overall cleanliness and checking of sharps bins.

The service mostly made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

The service had systems and processes in place to safely support people using services with their medicines in health-based places of safety (HBPoS) and crisis teams. People’s medicines were regularly reviewed by the multidisciplinary team (MDT) for clinical and side effects of medicines. Staff had access to GP care records including people’s current medicines and physical health results. This supported with prescribing decisions and medicines reconciliation. Medicines reconciliation is the structured process of creating the most accurate list possible of all a person’s current medications.

Pharmacy staff were embedded within the service, actively participating in meetings and providing clinical interventions. Staff told us pharmacy staff offered expert support on all aspects of medicines optimisation and delivered targeted training to enhance staff knowledge.

Staff handling medicines completed the trust’s safe administration of medicines training. Compliance with safe administration of medicines was 60% at Bedford Crisis Resolution Home Treatment (CRHT) team, 81% at Luton CRHT, 83% at City and Hackney Home Treatment team (HTT), 86% at City and Hackney HBPoS, 100% at Newham HTT and 77% at Tower Hamlets HTT.Following our inspection, the service provided information showing compliance with safe administration of medicines had increased to 100% in Bedford CRHT, 90% in Luton CRHT, 90% in City and Hackney HTT, 90% at City and Hackney HBPoS and 86% at Tower Hamlets HTT, it remained 100% at Newham HTT.

We observed medicines were stored safely and securely in locked cabinets with regular stock checks and temperature monitoring. FP10 pads and pre-packs of medicines were used appropriately for urgent supply in crisis teams. FP10 forms are the standard NHS prescription form in England used by GPs and non-medical prescribers to dispense medications via community pharmacies. Emergency medicines such as adrenaline were available.

Staff supported with clozapine initiation by providing the necessary physical health checks and side-effect monitoring for people in their homes. We observed care in which titration was slower than standard guidance to prevent adverse effects. Medicine titration is the process of gradually adjusting a medicine’s dose to find the most effective amount with the fewest side effects. This was for a person who had recently switched from a depot, to oral clozapine where the risk of adverse effects was higher. Depot medication is a long-acting, slow-release medicine, usually given as an intramuscular injection every 1–4 weeks, commonly used for antipsychotic treatments.

Individual records showed that people’s physical health monitoring was reviewed. This included for those prescribed antipsychotics and mood stabilisers. However, there was no robust system to provide assurance that these checks were carried out consistently across all sites.

Mental capacity was assessed, and consent was obtained from people prior to the administration of medicines in HBPoS. In one example, intramuscular rapid tranquilisation (RT) was used. This was only administered after the patient had been reviewed and formally detained under the Mental Health Act. Post-RT physical health monitoring had been completed in accordance with national guidance. Staff told us there was supported by senior oversight of RT use and this was reviewed daily during safety huddles.

Records showed that compliance with medicines had been discussed with people, and where necessary, crisis teams had provided support with daily administration.

Staff were able to share examples of medicines incidents. There was a culture of reporting and learning from medicines incidents. When incidents occurred, they were discussed, actions were agreed and implemented, and learning was shared across the team to help ensure people remained safe.

However, documentation processes and systems for recording medicines administration varied across crisis teams. This was not always in line with local policy. At Luton and Bedford, CRHT teams used inpatient prescription charts for prescriber instructions while recording medicines administration separately in care records or spreadsheets. At the City and Hackney site, Electronic Prescribing and Medicines Administration (EPMA) were available for recording medicines administration. However, we observed 1 instance where medicine administration was entered retrospectively, 3 days after the home visit. Between September and November 2025, staff completed 7 incident forms where medicines administration record charts had not been signed. These had been identified by the service, and a thematic review to identify common themes and learning relating to medicines and their administration across crisis services. This was due to be presented to the trust medicine committee in September 2026.