- SERVICE PROVIDER
East London NHS Foundation Trust
This is an organisation that runs the health and social care services we inspect
Assessment report published 1 October 2026
Contents
Ratings - Acute wards for adults of working age and psychiatric intensive care units
Our view of the service
Our view of this service
Date of inspection: 8-18 December 2025.
East London NHS Foundation Trust provides inpatient psychiatric treatment and care for male and female patients, many of whom are detained under the Mental Health Act 1983.
These services comprise total of 21 acute wards and 5 psychiatric intensive care units (PICU) for working-age adults located across East London, Luton and Bedfordshire:
- City Hackney Centre for Mental Health, London (5 acute wards, 1 PICU)
- Newham Centre for Mental Health, London (2 triage, 4 acute, 1 PICU)
- Tower Hamlets Centre for Mental Health, London (4 acute wards, 2 PICU)
- Luton Centre for Mental Health, Luton (3 acute wards, 1 PICU)
- Oakley Court and Townsend Court, Central Bedfordshire (3 acute wards).
We carried out inspection visits to the wards operated by the Trust from 8 to 18 December 2025. We visited 16 of the above wards:
City and Hackney, London
- Joshua (19-bed male acute ward)
- Conolly (18-bed female acute ward)
- Gardner (20-bed female acute ward)
- Bevan (15-bed male PICU)
Newham, London
- Ruby (15-bed male triage ward)
- Ivory (15-bed female triage ward)
- Emerald (18-bed female acute ward)
- Crystal (15-bed male PICU)
Tower Hamlets, London
- Globe (19-bed male acute ward)
- Roman (19-bed female acute ward)
- Rosebank (11-bed female PICU)
- Millharbour (11-bed male PICU)
Luton Centre for Mental Health
- Coral (21-bed male acute ward)
- Jade (9-bed male PICU)
Oakley Court, Bedfordshire
- Ash (19-bed female acute ward)
Townsend Court, Bedfordshire
- Townsend (20-bed female acute ward).
We announced our inspection shortly before our team arrived on site. We also carried out unannounced visits at night to Bevan, Joshua, Emerald, Ivory and Crystal wards.
The services were last comprehensively inspected in 2016 and rated outstanding overall, with no breach of regulations. We since carried out several focused inspections. These inspections did not result in us re-rating the service, however, following our inspection in 2023, we limited the rating for safe to requires improvement. At that time, we found breaches of regulation because the trust did not always meet its targets for compliance with staff mandatory training and supervision.
This inspection was comprehensive and covered all key questions and quality statements. We have combined the scores for these to achieve the overall rating. Following this inspection, the overall rating has changed to requires improvement.
We found breaches of regulations in relation to safe care and treatment, premises and staffing:
- Regulation 12: Safe care and treatment. Post-rapid tranquilisation (RT) records had not been completed correctly. Physical health monitoring for patients prescribed high-risk medicines was inconsistent. Risk assessments for prescribed medicines with known side effects were not consistently completed. Legal documentation was not completed correctly, resulting in medicines being administered unlawfully.
- Regulation 15: Premises. Not all premises where care and treatment was delivered were fit for purpose, properly maintained and free from offensive odours. Adequate toilets and bathrooms were not available to people using the service. There were sometimes delays in maintenance work taking place.
- Regulation 18: Staffing. Further work was needed to ensure all staff completed mandatory training and received regular supervision and appraisal.
We have asked the provider for an action plan in response to the concerns found at this inspection.
We found other areas that needed improving to meet best practice standards. We identified some gaps in safety checks on several wards. Record keeping around ‘when required’ (PRN) medicines was inconsistent. Intermittent observations were carried out at set intervals, making them predictable. Signage to say that informal patients could leave was not in place on all wards. Care was not always delivered in a person-centred way. Patients were moved without notice between Ash and Willow wards in response to bed pressures. Some discharges were delayed due to factors outside of the trusts control. We saw limited evidence of patient and carer voice or co-production at service level, and variation in how well Patient and Carer Race Equality Framework (PCREF) was embedded across the wards.
We also found areas of good practice. During our visits the wards were fully staffed. Staff reported an open and supportive culture where learning was shared. Staff regularly met as a team to discuss patient risks and share information. Staff worked well with other teams within the trust and externally. Wards participated in quality improvement and accreditation. Resuscitation simulation training was regularly delivered to staff on London wards.
Mental Health Act and Mental Capacity Act Compliance Summary
Mental Health Act
The service provides care to patients detained under the Mental Health Act 1983 (MHA) as well as informal patients.
Staff received mandatory training in the MHA and its guiding principles. Overall, 97% had completed this. Staff had easy access to administrative support and legal advice on implementation of the MHA and its Code of Practice. Staff requested support from a second opinion appointed doctor when necessary. Staff stored copies of patients' detention papers and associated records appropriately.
Records showed that staff explained to patients their rights under the MHA in a way that they could understand, repeated as necessary and recorded that they had done so.
However, consent to treatment authorisations were not always completed correctly, which meant that medicines were administered unlawfully. On Townsend, Globe, Roman and Jade wards patients were prescribed medicines that had not been authorised or with medicine indication information not completed.
The majority of patients and carers we spoke with reported not having information about Independent Mental Health Advocacy (IMHA) or not being aware of what it was. This was not in line with the statutory rights of qualifying patients detained under the MHA.
Staff ensured that patients could take Section 17 leave (permission for patients to leave hospital) when this had been granted.
Mental Capacity Act
We saw evidence that staff assessed and recorded capacity to consent appropriately for patients who may have had impaired mental capacity. Capacity was assessed for each significant decision that a person needed to make.
Staff had completed mandatory training in the Mental Capacity Act (MCA). Overall 83% were up-to-date with this. There were variations in compliance rates for this training, across Luton and Bedfordshire wards 72% of staff were compliant and on Lea Ward in Tower Hamlets, 73% of staff had completed this. In Luton and Bedfordshire, 50% of medical staff had yet to complete their MCA training.
People's experience of this service
We spoke with 65 patients and 13 carers across the wards. We attended a patient debrief, 4 ward rounds, a community meeting and reviewed a sample of community meeting minutes. People’s views about the service varied considerably.
Patients’ feedback about staff was mixed. Whilst the majority described most staff as kind, helpful and respectful, others were not happy with the way staff treated them. Some patients expressed particular unhappiness in how staff on duty at night responded to them.
Approximately half of the patients felt staffing issues impacted their care, and half did not always feel safe on the ward. Most patients shared concerns about escorted leave and availability or choice of activities. Some also said their individual needs had not been met and they did not feel sufficiently involved in their care or treatment. Welcome packs were not provided on all wards.
Feedback from carers was also mixed. Most carers spoke positively about staff and were generally pleased with their relatives’ care. The majority said they and their relatives felt safe on the ward. However, there was a consistent theme of poor communication with carers. Most did not feel sufficiently informed about their relatives’ care and treatment and reported difficulties in contacting staff.
Views about food, drinks and snacks on offer were mostly negative. These related to the quality, portions, availability, and dietary needs or personal preferences not being met. Feedback about the care environment was mixed and we heard repeatedly about environmental issues and limited access to fresh air.
During our visits, we observed staff always present in communal areas and engaging with patients in a positive and caring manner. However, we also witnessed instances when staff were less responsive to patients’ needs.