East London NHS Foundation Trust

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• 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 assessment we rated this key question good. At this assessment the rating has changed to 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.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff we spoke with knew what incidents to report and how to report them on the trust’s electronic system. We reviewed a sample of incident records across the wards. The records demonstrated that staff knew how to categorise incidents, recorded appropriate level of detail, actions taken and learning identified. Managers reviewed all incidents. Five of the 6 records we viewed at Newham were still awaiting manager sign off, which had not been done within the expected timeframe. Since our inspection, the service informed us that a new process had been introduced to escalate any outstanding sign offs on a weekly basis.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if things went wrong.

Staff and managers discussed incidents in a number of forums, including daily huddles, team meetings, handovers, reflective practice and awaydays. Learning from the wider trust was shared through alerts and seminars. Some wards had weekly reflective practice sessions facilitated by a psychologist. On other wards staff said that reflective practice largely took place in quarterly awaydays and was not as frequent as they would like.

Staff were able to share examples of recent incidents and learning from those. There had been changes in security procedures, physical health monitoring, and improved post-incident debriefs for patients. Improvements were also made as a result of audits, for example modifications to anti-barricade doors. The service was also working to improve therapeutic engagement following some incidents in which poor observation practice had been identified. We saw staff using zonal observations effectively across the wards and individual observations were reviewed daily.

We attended daily ward and unit-wide huddles where staff discussed earlier incidents, for example a patient assault on staff and a patient experiencing bullying from peers. Staff discussed and agreed actions to take. They also discussed support to be provided to any staff who reported not feeling safe and follow-up for those who were off work following the incident.

Verbal and physical aggression was a common type of incident, but staff said they felt safe working on the wards and received debriefs after incidents. Managers supported staff in reporting incidents to the police when appropriate. However, some patients told us they had not received debriefs.

The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. Staff discussed upcoming admissions, transfers and discharges in daily huddles. These meetings included a range of multidisciplinary roles who contributed to discussions and decisions taken.

The majority of the patients were admitted to wards near their home areas. This arrangement supported their regular contact with family, friends and local communities.

We reviewed 30 care and treatment records. Most of them showed that staff involved the necessary healthcare and social care services to ensure patients had continuity of safe care, both prior to and during the admission and on discharge. We saw evidence of involvement of community care coordinators, crisis resolution and home treatment teams, substance misuse services and social services. When relevant, staff also contacted carers to obtain patients’ full history. Two carers shared concerns in relation to the safety of their relatives’ discharge. On Ruby Ward we drew staff’s attention to one patient, due for discharge the next day, where we could not locate their safety plan.

The trust had introduced discharge hubs, whose role was to support patient discharge. The hubs were being strengthened with additional roles at the time of our inspection to improve patient flow. Due to the pressures across the entire health and social care system some challenges in relation to discharge remained outside of the trust’s control.

The evidence showed a good standard. 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.

Staff received mandatory training in safeguarding adults and children and PREVENT (training aimed at safeguarding people from the risk of radicalisation and extremism). Overall, over 86% staff had completed safeguarding training to the level appropriate to their role and 92% PREVENT. There were however some wards where compliance levels with safeguarding training was lower. On Onyx Ward 67% staff had completed level 2 in adult safeguarding and 69% safeguarding children. On Jade Ward, the completion of level 3 safeguarding adults and children training was 60% and 70% respectively. Following our inspection, we were provided information to show that training compliance on both wards had improved.

Staff we spoke with knew how to recognise individuals at risk of or suffering harm and were aware of the risks specific to their patient group. Staff escalated concerns appropriately to managers and worked with other agencies such as local authorities and the police. Safeguarding was discussed regularly in daily huddles, supervision, team meetings, reflective practice and awaydays. Most staff knew the safeguarding leads and said they were easily accessible. The details of safeguarding leads for adults and children were displayed on the wards. Patients could raise safety matters in weekly community meetings.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act 2010. For example, staff on Bevan, Gardner and Joshua wards told us about using anti-discriminatory practices in supporting transgender patients to ensure their safety, dignity and wellbeing, as well as that of other patients.

Staff followed safe procedures and risk assessed children visiting the service. Most family visiting facilities were located away from the wards, however on Ash, Conolly and Gardner wards the visiting rooms were on the wards.

There were some restrictions in place on the wards, which were proportionate to maintain a healthy and safe environment. For example, outdoor access and some areas with ligature anchor points were supervised. Staff maintained and reviewed blanket restriction registers. However, although drinks and snacks were freely available on most wards, on Jade Ward patients had to request drinks, and on Gardner snacks were provided on request.

The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 30 care and treatment records across the wards. Most contained risk assessments completed on admission that were regularly reviewed and updated. Some shortfalls were noted in 7 patients risk assessments. For 1 patient on Coral Ward the assessment did not include all areas of risk, such as risk to self and others. One risk assessment on Ruby Ward was completed 2 days after admission and the key risk had not been fully reflected in it. For another patient on Ruby Ward, the risk management and safety plans needed updating. For 1 patient on Crystal Ward, the safety plan was last updated in June 2025 by the community team. In addition, for 3 patients their risk assessments were not personalised, or lacked sufficient detail.

Staff across the wards received training in safety intervention and overall, 80% had completed it. There was however variation across wards, with some having lower compliance rates. On Onyx Ward 63% of staff were compliant, 67% on Townsend Ward, 69% on Ruby, 71% on Brick Lane, and 70% on Jade, Rosebank and Ruth Seifert wards. Compliance with this training was lower across Luton and Bedfordshire wards at 74%, when compared with London wards. Some staff were exempt from this training due to health reasons and completed breakaway training instead.

Staff we spoke with told us about their commitment to least restrictive practices and using restraint only as the last resort. We reviewed a sample of incidents records of restraint and seclusion. Most contained records of de-escalation attempts and documented the restraint appropriately. However, at Newham, one seclusion record was missing a nursing review entry and 2 restraint records missed documentation of limb holds. Five patients we spoke with told us about being restrained or witnessing other patients being restrained. Three of them were not happy with how staff carried out restraints.

Staff carried out different levels of observations and reviewed these based on individual need and risk. When patients required increased observation levels,an appropriate rationale was recorded, withevidenceof multidisciplinary team input. There was ongoing quality improvement work on 7 wards to reduce the use of unnecessary intermittent observations, with a view to increasing therapeutic engagement and improving safety. We found variation in how staff completed intermittent observations across the wards. For example, on Townsend Ward, these were randomised. On other wards including Conolly, Gardner, Bevan, Coral, Ash, Ivory, Ruby intermittent observations were carried out at set intervals, meaning they were predictable. On Emerald and Crystal wards, night observations were at predictable intervals, although observation records during the day were randomised. One observation record on Townsend Ward lacked the detail of patient’s presentation at each observation point.

Patients’ views on how staff completed observations varied. Whilst some said that staff conducted observations respectfully and appropriately, 3 patients shared concerns in this area. Some did not think that staff carried out observations appropriately and others did not know what level of observation they were subject to.

Staff involved patients in risk assessment and care planning, with evidence of patient voice in most records. However, on Emerald Ward patient involvement was less evident. Of the 78 patients and carers we spoke with, 15 patients and 9 carers were dissatisfied with their level of involvement.

Approximately half of the patients we spoke with did not always feel safe on the wards. They described being involved in incidents, feeling intimidated by the environment and having witnessing incidents. There was a repeated theme of feeling less safe at night. Seven patients across Ash, Bevan, Coral, Townsend and Jade wards shared concerns about night staff. One said: “Night staff don’t do their duties”. Four patients who attended a debrief meeting on Conolly Ward said they did not feel safe at night as they felt that incidents were more likely to happen and they did not trust that staff would intervene.

Following our inspection, the trust updated us on its plans to review and strengthen its approach to risk assessment, observations, night safety and restrictive practices.

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

We viewed a sample of safety checks across the wards, most of which were up-to-date. However, on Millharbour Ward, some daily room and environmental checks had not been completed. On Globe and Jade wards, the clinic rooms contained some out-of-date items which we reported to the managers who removed those immediately. On Ruby and Crystal wards, the kitchen fridge temperatures were not being recorded.

Further work was needed to keep patients safe from ligature risks. Whilst most potential ligature anchor points were identified and mitigated adequately, some items were missing. On Townsend Ward an outbuilding had not been included in the ligature risk assessment. On Ruby Ward we identified potential ligature risks within patient bedrooms. We also escalated concerns about some fittings within patient bedrooms and ensuites on Globe, Millharbour, Ivory and Crystal wards. These were escalated to staff immediately. During our inspection, work was in progress to replace all bedroom and bathroom doors across wards with anti-ligature ones. Some items on the ligature risk assessments on Coral and Ash wards were shown as pending for completion. Following our inspection, the trust has taken action to remove or mitigate these ligature risks.

Overall, the wards appeared tired and worn. There were significant shortfalls in maintaining various aspects of the environments that we visited. We heard that the service had experienced challenges with maintenance following a recent change of contractor. This meant that staff had to re-submit some maintenance requests and there were delays to repairs. Staff shared their frustrations about this, for example a blocked sink and a faulty light on Joshua Ward were reported some days earlier. On Ivory and Crystal wards there were delayed repairs to broken glass windows. On Bevan, Gardner and Coral wards, water dispensers were broken. The ensuite shower rooms on Globe Ward had some mould and rust, and the kitchen had remained locked for several weeks after an incident. On Millharbour, some armchairs were ripped. On Jade and Rosebank wards, information boards had been damaged by patients. Staff told us that damage to the wards was sustained regularly. Patients also shared their concerns about the ward environments with us during the inspection.

Some wards experienced recurring pest infestations, despite staff reporting these promptly. We saw fruit flies on Bevan, Joshua and Conolly wards and a rat on Roman Ward. Staff and patients told us about recent mice sightings on Townsend, Joshua and Conolly wards.

The majority of the wards we visited had communal bathroom and toilet facilities. These were not always sufficient for timely access to essential sanitary provision. For example, on Townsend Ward, a corridor of 10 female bedrooms was served by 2 showers and 1 toilet. Shared facilities also meant that frequent plumbing issues impacted multiple individuals. During our visits, there were several blocked toilets and showers on Jade, Conolly and Gardner wards. Communal showers on Conolly smelt of urine. On Bevan Ward, both staff toilets were out of use, requiring staff to use toilets on the adjacent Joshua Ward which caused disruption to staff and patients on both wards. Staff told us this had been happening on and off for some weeks.

Although each site had access to appropriate seclusion facilities shared with other wards within the unit or nearby, during our visits most of those were out of use due to environmental issues. At City and Hackney, the seclusion room was not in use due to patient damage and a faulty shower. At Luton, it was closed because of drainage issues. This meant that staff would need to make alternative arrangements for any patient that required nursing in seclusion, such as using another seclusion facility or a vacant place of safety. At Tower Hamlets, the seclusion room was in use, however there was an offensive smell in it and on the adjacent female PICU (Rosebank Ward).

When we carried out an unannounced night visit to City and Hackney Centre the following week, staff toilets on Bevan Ward were still out of order and seclusion facilities remained out of use.

Some wards had access to gardens. Other wards had no direct outdoor access, for example Conolly and Brett due to being on the first floor. Additionally, 3 bedrooms on Conolly Ward did not have windows and therefore no natural light. Outdoor access was timetabled and required staff supervision, and 10 patients across the wards told us this was an issue due to staff availability. We saw limited garden use during our site visits.

Most wards had adequate space and rooms for the number of patients admitted, such as communal lounges, activity rooms, activities of daily living (ADL) kitchens and quiet rooms. However, on Jade Ward the lounge was used for therapies and activities and there was no sensory or quiet room.

Staff carried out regular risk assessments of the care environment. They also completed relevant training. Ninety-one percent of staff had completed fire safety training and 94% had completed health and safety training.

The service admitted male and female patients. There were no mixed sex wards, and each patient had their own bedroom. Most patients had access to their rooms throughout the day. On Ruby and Joshua wards patients relied on staff while the key fob system was replaced. Some patients had personalised their bedrooms.

Staff had access to alarms and patient rooms had nurse call systems. These were tested daily. Most wards had some blind spots which were mitigated by the use of CCTV, mirrors and observations. There was no CCTV on Conolly Ward and staff shared their concerns about this. Additionally, on the same ward the treatment room hatch could be opened from the outside, which staff were aware presented a safety concern. Since our inspection, we have been informed that this door was scheduled to be replaced.

The evidence showed some shortfalls. Whilst the trust used a recognized model to ensure there were enough qualified, skilled and experienced staff, some wards described feeling under pressure and stretched. Some improvements were needed to make sure all staff were up to date with their training, supervision and appraisal. Staff worked well together to provide care that met patients’ needs.

During our site visits, all the wards had met their safe staffing numbers. We saw staff always present in the communal areas of the wards. However, half of patients we spoke with said that staff were not always available. They told us their escorted leave or outdoor access could be limited or delayed due to staff availability. For example, during a debrief meeting on Conolly Ward patients raised only having had 10 minutes of garden access in 48 hours due to staff availability.

Approximately half of the staff we spoke with thought there were staffing challenges, especially during increased acuity or if staff were required for off-ward activities such as escorted leave. On Joshua Ward staff were trialling group leave to the park or shops in order to better meet this need.

Managers reviewed staffing levels each morning in unit and safety huddles and adjusted those according to the changing needs, for example when patients were nursed on enhanced observations. In the unit huddles we attended, no staffing issues were identified. Managers deployed bank staff when needed, and there was no agency staff use. We heard that bank staff were usually regular and familiar with the wards. Staff told us that managers also helped when they could.

There was adequate medical cover day and night on most wards and a doctor could attend quickly in an emergency. Medical cover on night shifts at Tower Hamlets was shared with the local acute hospital emergency department. At the time of our inspection, the consultant on Bevan Ward additionally covered 2 other wards due to colleague absences.

Vacancy rates varied across the wards. Only Ruby, Topaz, Brick Lane and Rosebank wards did not have vacancies for any staff grade at the time of our inspection. City Hackney, Newham and Tower Hamlets directorates had over 90% of posts filled. Ivory Ward had the highest vacancy rate at 21%. Luton and Bedford directorates were staffed with just over 80% of posts filled. The highest vacancy rates were on Ash (31%) and Townsend wards (29%).

In the 6 months prior to our inspection, average sickness absence rate was around 6% across all wards. During this period, Onyx Ward had the highest sickness rate at 17%, followed by Sapphire (15%) and Ruth Seifert (14%).

New starters received ward- and unit-specific induction, as well as trust induction for new staff.

Whilst the trust had identified mandatory training for staff and had achieved an overall compliance rate of 89%, further work was needed to make sure all staff completed their training and each ward and directorate met their target. The training was appropriate for the patient group using the service.

Compliance was low for some courses. Across all wards the completion of breakaway training was 54%. Breakaway training was aimed at staff who were exempt from safety intervention training due to health reasons. Although managers told us they took account of this when creating rotas, the low completion of this training created the risk that not all staff could disengage safely in an incident. Newham wards had the lowest compliance with breakaway training at 24% overall.

Across all wards compliance with safer prescribing of medicines training was 57%. On Luton wards, 65% of medical staff had completed safer prescribing of medicines.

Across Bedford and City Hackney wards, basic life support training completion was 74% and 73% respectively. The trust delivered hands-on resuscitation simulation training to improve staff competence in responding to medical emergencies. At the time of our inspection this training had been taking place weekly across the London wards, with plans to start delivering it in Luton and Bedfordshire. At Tower Hamlets, rapid tranquilisation training completion was 70% on Lea and 73% on Millharbour wards.

Whilst trust wide work was underway to improve the quality of supervision and appraisal, there was more work to do to ensure that all staff received regular supervision. At City and Hackney, completion of 6-weekly managerial and clinical supervision was between 59% and 72% on Brett and Bevan wards. At Newham, managerial and clinical supervision was 41% on Ruby Ward and 72% on Topaz Ward. On Crystal Ward managerial supervision compliance was at 63%. In Tower Hamlets, 61% and 64% of staff had received managerial and clinical supervision respectively. This meant that managers may not always deal with poor staff performance promptly and effectively.

We also found considerable variation in annual appraisal completion. Whilst over 85% of staff at Bedford, Luton and Tower Hamlets had completed their appraisal, the average compliance rate across City Hackney was 26% and in Newham 21%. On Joshua, Crystal, Ruby and Topaz wards no appraisals had been completed.

The evidence showed a good standard. 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.

Over 89% of staff had completed the infection prevention control (IPC) training. The care environment on the wards was visibly clean and tidy during our inspection. ‘Clean’ stickers were visible and in date. As the service used an external cleaning contractor, they kept their own records which were not accessible to staff.

Staff adhered to infection control principles, including handwashing. IPC posters were displayed on the wards and staff we spoke with knew who the local IPC leads were.

Staff completed regular IPC audits on each ward. However, on Ash Ward, it was not clear when the most recent monthly audit was completed and whether the issues identified had been addressed.

Staff discussed IPC matters in daily huddles. For example, at the City and Hackney unit huddle, staff were advised of additional IPC measures during the winter flu outbreak.

The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Improvements were needed to ensure that patients received information in relation to the medicines they were prescribed. Over half of the patients and carers we spoke with were not satisfied with the information they had been provided about medicines or reported issues in this area. For example, one patient said they had not been informed about a recent change in their medicine, and another that their prescribed medicine was not added to the system following their admission. Another patient told us they did not feel listened to when they had raised concerns about their medicines side effects. In a ward round we observed, a patient who was due to be discharged told staff that they had not received an information leaflet about their prescribed medication and researched it online instead.

Medicines were not always managed safely or consistently across the wards. Whilst there were appropriate systems and processes in place, these were not always followed.

Staff told us where restrictive practice was used, they completed incident reporting, post‑event reviews and safety huddles to support learning.

During our review of patient care and treatment records, we found in some instances that post‑dose physical health monitoring following rapid tranquilisation (RT) via the intramuscular route was not consistently completed or recorded, in line with national guidance. When 'as required' (PRN) medicines were used for the management of anxiety or agitation, staff did not always record the reason for use or if it had been effective. Although some medicines were prescribed for agitation, some patients were administered these medicines at night, and records did not consistently demonstrate that the reasons for administration aligned with the prescribers’ indicated use for agitation. Therefore, we could not be assured these medicines were being used appropriately.

Medicines were stored safely and securely. Pharmacy teams visited wards daily and worked well with the multidisciplinary team. Pharmacists attended ward rounds and used these opportunities to provide guidance and support, including teaching staff about psychotropic medicines and their monitoring requirements.

Staff completed medicines reconciliation (the process of gathering an up-to-date list of a person’s prescribed medicines) when patients were admitted onto the ward, helping to reduce the risk of errors. Staff had access to systems which allowed them to view patients’ physical health records such as blood test results and GP summaries. We saw allergies were clearly recorded on all medicine charts.

Staff liaised with specialists from acute hospitals when patients had complex physical health needs, including cardiology and diabetic nursing teams. Staff reviewed patients’ medicines regularly as part of the multidisciplinary meeting (MDT) and provided specific advice to patients about their medicines. However, monitoring arrangements for people taking high risk medicines was inconsistent. For example, some wards did not have physical health monitoring plans in place for patients prescribed high dose anti psychotic therapy (HDAT) or high‑risk combinations of medicines. Bowel monitoring for one patient prescribed clozapine (an antipsychotic with known health risks including constipation) had not been recorded consistently despite the doctor having identified this to be completed. This placed the person at risk of experiencing preventable harm.

Legal documentation did not always align with prescribed treatment. We saw examples where consent documentations for patients detained under the Mental Health Act (MHA) did not match with the current prescriptions.

For prescribed medicines containing valproate (a medicine with known side effects on people of childbearing potential) risk assessments were not consistently completed in line with local expectations and national guidance. On Bevan Ward, 2 valproate risk acknowledgement forms were missing or overdue.

On some wards we saw missed doses where medicines were not available and these omissions were recorded on EPMA (electronic prescribing and medicines administration system). For patients prescribed depot antipsychotics, injection sites were not consistently recorded, therefore we could not be assured that injection sites were always rotated in line with manufacturer’s guidance to reduce the risk of adverse effects.