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 as good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

All wards were safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to young people and themselves effectively. Risk management processes were embedded within multidisciplinary team (MDT) discussions, and we saw evidence of good quality risk formulation and collaborative review of risk within team meetings.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Quality statement score: 3.

The evidence showed a good standard.

The service had a proactive and positive culture of safety, underpinned by openness, honesty and reflective practice.

Staff understood their responsibilities in relation to incident reporting and were able to describe the processes for escalating concerns. Incident reporting was comprehensive, and learning from incidents was effectively disseminated across the service to reduce the risk of recurrence.

We reviewed 6 serious incidents across the service and found evidence of good-quality incident recording processes, with lessons learned appropriately identified, discussed and shared across teams to support continuous improvement and safer care delivery.

The service demonstrated a strong learning culture in which staff were encouraged to reflect on practice and share learning from incidents, complaints and feedback. Staff told us learning was regularly cascaded through team meetings, handovers and reflective discussions. The service also used staff away days to facilitate learning for the teams. Away days were used to support both learning and team development. These included a focus on operational priorities, such as reviewing audit findings and strengthening staff competencies in areas including observation practice, as well as wider developmental learning.

Staff demonstrated a good understanding of the duty of candor. They were able to describe how they were open and transparent with young people and families when things went wrong, including providing honest explanations, offering support and identifying learning to improve future practice.

Quality Statement Score:3.

The evidence showed a good standard.

The service worked with a range of partners to establish and maintain systems of care, to promote patient safety. They made sure there was continuity of care, including when people moved between different services.

The service worked collaboratively with system partners. In London the North Central and East London (NCEL) provider collaborative supported timely access to the appropriate Tier 4 CAMHS inpatient provision for young people requiring specialist mental health care. The referral and admission processes ensured that essential information about young people was obtained to determine whether their needs could be safely and appropriately met within the CAMHS units. Staff also worked effectively with partner agencies and the provider collaborative to gather and review relevant information to support safe admission decisions and continuity of care.

Referral pathways into the services included community CAMHS teams, crisis teams and urgent care services. The services accepted referrals nationally, although at the time of the inspection approximately half of admitted patients originated from East London. The NCEL provider collaborative provided oversight and coordination of referrals through a centralised bed management system, supporting effective placement allocation and patient flow across the provider collaborative.

The service operated a structured pre-admission process, referred to as ‘porch meetings’, where referrals were reviewed collaboratively with the young person and their families, and the referrer and provider collaborative partner. These discussions considered all available referral information and explored whether the young person’s needs could be safely and appropriately met through community or home-based support. Staff told us this approach was an important part of the service’s pathway, as it helped ensure that inpatient admission was only considered when less restrictive alternatives had been fully explored and were not suitable to meet the young person’s needs.

On discharge, most young people are referred to their local community CAMHS teams. Young people living locally could also access the day service provided by the Coborn unit where clinically appropriate.

The service benefited from involvement in wider system collaboration, including the Provider Collaborative and PICU Advisory Group, which supported oversight and development of care pathways. Leaders described ongoing investment in alternative care pathways and a shift in culture towards reducing length of stay and improving patient flow, reflecting longer-term sustainability planning.

Quality Statement Score: 3

The evidence showed a good standard.

Staff understood how to protect young people from abuse, and safeguarding processes were well embedded within day-to-day practice. The service worked effectively with partner agencies to support safeguarding arrangements and promote the welfare and safety of young people.

Training compliance data demonstrated that staff had generally completed mandatory safeguarding training appropriate to their roles, supporting the service’s ability to safeguard young people effectively. Overall compliance with mandatory safeguarding training across the service was 78%. Training compliance was recorded on the service risk register, with clear actions and trajectories in place to achieve full compliance. Staff requiring updated safeguarding training had been identified and were booked onto sessions, with completion planned by the end of March 2026.

Staff we spoke to demonstrated a good understanding of safeguarding responsibilities and knew how to identify, escalate and report safeguarding concerns. For example, staff told us how they developed individual sexual safety plans for young people where concerns relating to sexualised behaviours had been identified. These plans supported staff to manage risk appropriately and support adolescent development while maintaining a therapeutic and trauma informed approach. Staff also described how they promoted healthy, age appropriate and respectful relationships between young people within the ward environment in a safe and structured way.

Quality Statement Score: 3.

The evidence showed a good standard.

The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 16 young people’s care records and found good quality documentation relating to risk assessments and risk management plans. Records demonstrated that staff responded appropriately and proactively to incidents, with risks reviewed regularly and updated in line with young people’s changing needs and presentations.

Care records evidenced consistent involvement of young people and their families in care planning and risk management discussions. We saw evidence of ongoing multidisciplinary professional engagement, with staff from a range of disciplines contributing to assessments, reviews and treatment planning.

We attended the daily Senior Management Group (SMG) meeting, which included charge nurses, lead nurses and wider multidisciplinary team representation. The meetings provided a structured forum to discuss young people’s risks, presentations and care needs. Discussions were positive, collaborative and focused on the best interests of the young person.

The multidisciplinary team reviewed current risks, triggers, observations, incidents, mood, presentation, medication, activities, educational engagement and next steps in care planning. Staff demonstrated a good understanding of individual needs, including discussions relating to neurodiversity and adjustments required to support young people effectively. Staff knew about any risks to each patient and acted to prevent or reduce these. Key information was consistently shared to maintain patient safety, including during shift changes, handovers and multidisciplinary meetings. These forums included all necessary information, such as updates to patient risk and the allocation of risk management activities to individual staff members, ensuring a coordinated approach to care and risk management. We also observed discussions relating to positive progress, including the reduction of observation levels where clinically appropriate.

Staff carried out different levels of patient therapeutic observations and reviewed these based on individual need and risk. Observation records were up to date and accurately completed. Observation levels for patients were recorded in patient records and updated as they were any changes. Observation records were included in the service audits and manager also conducted spot checks to ensure compliance with the trust’s therapeutic observation processes. Risk management discussions within staff and service meetings were thorough and person centred. Staff described how key working sessions were held weekly with young people to gather information and support collaborative care planning and risk review processes. Young people also had allocated care managers to support coordination of care and continuity across services.

Staff demonstrated a balanced and collaborative approach when making decisions in the best interests of young people. For example, staff told us that parents’ views regarding medication were respected and considered; however, decisions were made collaboratively with the young person wherever possible to support shared decision-making and promote the young person’s autonomy and wellbeing.

The Galaxy PICU ward had one seclusion room; however, this was out of use at the time of our inspection. We reviewed 7 seclusion records and found good standards of record keeping and oversight relating to restrictive interventions. Documentation included the use of nasogastric (NG) trackers, seclusion trackers, restraint trackers, post-rapid tranquillisation reviews and reflective practice records. The service used social stories with young people following incidents of seclusion to support the understanding of triggers, behaviours and emotional responses. These were developed collaboratively with the young person and incorporated into multidisciplinary team (MDT) case formulation and safety plans, enabling a more personalised and trauma-informed approach to care. This supported staff to better understand the underlying factors contributing to behaviours, and to adapt risk and care plans and interventions to reduce the likelihood of incidents recurring. In the Evergreen unit, leaders told us there had been no patient safety incidents requiring seclusion within the last three years. This reflected the service’s focus on preventative and therapeutic approaches to managing distress and risk. Records demonstrated that staff followed the trust’s rapid tranquillisation policy appropriately.

We saw evidence that staff attempted de-escalation strategies prior to the use of restrictive interventions. This included the use of sensory-based approaches. Young people were supported to access sensory boxes, a sensory room and a low stimulus room where appropriate, enabling them to self-regulate and reduce distress. Records showed that incidents were reviewed appropriately, and post-incident debriefs were completed with both staff and young people where appropriate. These approaches helped inform ongoing risk and care planning.

Documentation also demonstrated that physical health monitoring was undertaken following restrictive interventions and rapid tranquillisation. This included the use of a digital observation system to monitor patients’ observations in real time in the Galaxy PICU ward seclusion room. Records evidenced ongoing clinical reviews and monitoring to ensure young people’s safety and wellbeing during and after incidents involving restrictive practice.

Quality Statement Score 3.

The evidence showed a good standard.

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

We conducted an environmental tour of all 5 wards visited across the service.

We found the environments and wards across the services appropriately equipped and maintained to support the safety and therapeutic needs of young people.

Staff completed regular environmental risk assessments across all premises, including ligature risk assessments and environmental walkaround audits. Risks identified within the environment were monitored and managed appropriately to support patient safety. Each ward had a ligature map in the staff office. Staff were aware of potential ligature anchor points and supervised these areas. Mitigating actions where ligature risks were identified included increased observations by staff and areas such as the kitchens, meeting rooms, laundry rooms and education rooms were locked when they were not in use. We reviewed emergency equipment, including emergency grab bags and ligature cutters, and found these to be appropriately checked and maintained.

The service demonstrated collaborative working with young people in relation to the ward environment. Young people were encouraged to contribute feedback through regular community meetings and Patient Reported Experience Measures (PREMs), which staff encouraged young people to complete weekly. Staff used this feedback to inform discussions regarding the environment and service improvements.

We identified some environmental issues across the Coborn centre. Staff told us there had been damage to parts of the environment caused by some young people. For example, the television screen in the Pluto lounge area had been scratched, and the television vision in the PICU environment was temporarily out of use due to damage at the time of inspection. These were both logged for repair. We also received reports of drainage and plumbing issues affecting some bedrooms. On Galaxy ward, some equipment within the sensory room was awaiting repair or replacement.

Quality Statement Score:3.

The evidence showed a good standard.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

At the time of inspection, we found that staffing levels and skill mix within the wards were determined based on the assessed needs of the young people using the service. Managers told us they were able to access additional staffing when required, including the use of regular bank staff to ensure safe care delivery. At the Coborn center, the managers informed us that where increased risks were identified, requests for additional staffing were authorised promptly, with patient safety prioritised above financial considerations. The service demonstrated flexible and responsive workforce planning through the utilisation of enhanced staffing models, including Extraordinary Packages of Care (EPOC). This model involves funding and commissioning specialised, high-level care plans for young people with complex or high-risk needs, particularly during periods of crisis. EPOC enabled a temporary increase in staffing levels, often on an enhanced observation ratio, to promote safety, improve engagement, and provide intensive support on the unit.

The service, across both site, operated with a full multidisciplinary team (MDT), which included psychiatrists, nurses, occupational therapists, education staff, and access to psychologists, social workers, and who worked together to support the care and treatment of young people. Overall, staffing levels were considered adequate for both the Coborn wards and the Evergreen unit, with systems in place to mitigate and manage risks effectively.

However, the service had identified vacancies in consultant psychiatry posts, which were recorded on the risk register as a potential risk to safe and effective care delivery. The service was actively working to address this through ongoing recruitment campaigns. In the interim, existing ward consultants provided cross-cover arrangements, prioritising high risk cases to maintain clinical safety and oversight. The clinical director, who was also one of the ward consultants, maintained oversight of consultants’ caseloads to ensure appropriate clinical review and risk management.

Each staff member received mandatory training including the Mental Health Act, Mental Capacity Act, resuscitation and life support for paediatrics, risk management, medicines management, equality, diversity and human rights, infection prevention and control, prevent, safeguarding and Oliver Macgowan training. Overall compliance for mandatory training at the time of our assessment was at 94% with no modules less than 70% compliant. Training data included staff members who were not active in the service for example, those on long term sick or maternity leave, which brought compliance figures down. The service risk register included training compliance with an associated action plan with a trajectory to have all outstanding training completed by the end of July 2026.

Training included Trauma Risk Management and Reinforce Appropriate, Implode Disruptive behavioural approach), which gave staff the skills and confidence to recognise and respond to trauma-related behaviours, de-escalate challenging situations, and promote positive behavioural support. This supported staff to provide consistent, therapeutic responses to distress, reduce the use of restrictive interventions, and create a safer, more supportive environment for children and young people, aligned with their individual needs and experiences.

Other training included understanding neurodiversity, improving communication and interactions with young people, and supporting young people’s emotional, social and developmental needs, including appropriate boundaries and relationships. This supported staff to reflect on practice and deliver care in a more consistent and informed way.

Line managers supported most staff through regular, constructive clinical and operational supervision of their work. The datasubmittedat the time of inspection, showed overall supervision compliance as 91% for CAMHSInpatient Services. Most staff said they found supervision with their line managers very helpful. During supervision sessions, staff talked about their clinical support, personal development and training, service issues and challenges at work along with administrative matters such as leave and sickness.

Managers supported most staff through regular, constructive appraisals of their work. Most staff had a performance appraisal each year and planned their professional development for the following year. Staff felt that appraisals were an important part of continuing professional development as it allowed them to reflect on their current performance and development.

Following the inspection, the provider submitted further evidence to show that current overall appraisal compliance is 96%, compared with 78% in March 2026 at the time of the inspection.

Staff had access to additional supportive formats, such as reflective practice sessions.

Quality Statement Score: 3.

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.

The wards across the service were generally clean and well maintained. Staff maintained equipment well and kept it clean. There were in date ‘clean’ stickers visible on the equipment. Ward areas were clean, had good furnishings. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly.

The service demonstrated a good standard of infection prevention and control training compliance, supporting safe care delivery. Staff we spoke with were aware of infection prevention, control requirements and policies, including appropriate use of personal protective equipment (PPE).

All staff received infection prevention and control training as part of their mandatory training, the compliance level at the time of our assessment was 90%.

Quality Statement Score: 3.

The evidence showed a good standard. The service 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.

We reviewed medicines related documents, for example the prescription and administration records, and medical notes. We also spoke to nurses, a lead pharmacist and a dedicated ward pharmacist. At the Coborn unit, a senior pharmacist covered the three wards with the support of pharmacy technicians. The Evergreen unit had a dedicated pharmacist, managed by the ward manager.

The services had systems and processes in place for the safe and effective use of medicines. Staff told us that where restrictive practice was used, such as medicines to sedate a young person, they completed incident reporting, post‑event reviews and safety huddles to support learning. We saw evidence of post‑dose physical health monitoring following rapid tranquilisation administration via the intramuscular route in line with national guidance.

Pharmacists worked well with the multidisciplinary team and attended ward rounds, using these opportunities to provide guidance and support, to staff and patients around medicines. They also reviewed monitoring requirements and ensure appropriate weight-based prescribing in line with national guidance for child and adolescent mental health patients in line with national guidance.

Staff told us how they report medicines incidents and how learning from these incidents were shared.

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 patient’s physical health records such as blood test results and GP summaries. We saw allergies were clearly recorded on all medicines charts.

Staff regularly reviewed the effects of medicines on patients’ mental and physical health. We saw appropriate monitoring arrangements in place for patients prescribed high-dose antipsychotic therapy and high-risk combinations of medicines. This included physical health monitoring for specific medicines, such as lithium, olanzapine and quetiapine, in line with expected practice. The pharmacist described the monitoring requirements for patients prescribed clozapine, although there were no patients receiving clozapine at the time of inspection. Staff had access to Health Information Exchange (HIE), which allowed staff to securely share patient health data electronically.

We saw evidence that a choice of medicines leaflets were available to patients. We saw that Mental Health Act paperwork, including T2 and T3 authorisation forms, was in place where required, and medicines were administered in line with appropriate legal authorisation.

Staff demonstrated awareness of the STOMP (Stopping Over Medication of People with a Learning Disability and/or Autism) principles and told us they followed these in practice.

Medicines, including controlled drugs, were stored safely and securely within locked cupboards in the treatment room. Staff undertook daily temperature monitoring of medicine storage areas, which were maintained within the recommended range.

Emergency medicines and equipment were available and checked routinely to ensure they were fit for use.