Hertfordshire Partnership University NHS Foundation Trust

Updated 26 May 2023

Our rating of the trust improved. We rated it as outstanding because:

• We rated safe, effective and responsive as good and caring and well led as outstanding. In rating the trust, we took into account the previous ratings of the five services not inspected this time. We rated the trust overall for well led as outstanding. At this inspection, we rated two core services as outstanding, and four core services as good. Therefore, four of the trust's 11 services are rated as outstanding and seven as good.
• The trust responded in a very positive way to the improvements we asked them to make following our inspection in January 2018. At this inspection, we saw significant improvements in the core services we inspected and ongoing improvement and sustainability of safe, good quality care across the trust. The senior leadership team had been instrumental in delivering quality improvement and there was a true sense of involvement from staff, patients and carers towards driving service improvement across all areas.
• We were particularly impressed by the strength and depth of leadership at the trust. The trust board and senior leadership team displayed integrity on an ongoing basis. The board culture was open, collaborative, positive and honest.
• The trust’s non-executive members of the board challenged appropriately and held the executive team to account to improve the performance of the trust. The trust leadership team had a comprehensive knowledge of current priorities and challenges and took action to address them. The board were seen as supportive to the wider health and social care system. The trust’s chief executive had led on the Hertfordshire and West Essex sustainability and transformation plan (STP) for the region between August 2016 and January 2018. Reports from external sources, including NHS improvement and commissioners were consistently positive about the performance of the trust. The trust had a clear vision and set of values with safety, quality and sustainability as the top priorities. The trust benchmarked their ‘business as usual’ against the vision and values and kept the message at the heart of all aspects of the running of the organisation. Local leadership across the trust was strong, visible and effective. Staff were particularly praising of the chief executive, the medical director and the chief nurse. Succession planning was in place throughout the trust, aligned to the trust strategic objectives.
• The trust strategy and supporting objectives and plans were stretching, challenging and innovative, while remaining achievable. The trust aligned its strategy to local plans in the wider health and social care economy and had developed it with external stakeholders. The trust’s strategy recognised the need to be inclusive through established networks and partnerships. The trust had a clear vision and set of values, developed in collaboration with over 800 patients, carers and staff, with safety and quality as the top priorities. We were very impressed at how the trust’s vision and values were embedded throughout services and at board level and informed how the senior leadership team operated.
• Leaders showed an inspiring positive culture with a shared purpose towards the vision, values and strategy, and modelled and encouraged compassionate, inclusive and supportive relationships between all grades of staff. The trust ensured staffing levels and skill mix were planned, implemented and reviewed to keep people safe at all times. Overall, staff received appropriate training, supervision and appraisals to support them in their roles. The trust had introduced a new data management system which had provided greater oversight to staff compliance with mandatory training and supervision. All staff and managers had access to the system, although some managers were awaiting training.
• Staff showed caring, compassionate attitudes, were proud to work for the trust, and were dedicated to their roles. We were impressed by the way all staff in the trust embraced and modelled the values. The values were embedded in the services we visited and staff showed the values in their day-to-day work. Throughout the trust, staff treated patients with kindness, dignity and respect. Consistently, staff attitudes were helpful, understanding and staff used kind and supportive language patients would understand. The style and nature of communication was kind, respectful and compassionate. Staff showed strong therapeutic relationships with their patients and clearly understood their needs. Staff offered guidance and caring reassurance in situations where patients felt unwell or distressed, confused or agitated. Overall, positive feedback was received from those patients, families and carers spoken with about the care and treatment received from staff.
• Patients told us they felt safe across the trust. The trust promoted a person-centred culture and staff involved patients and those close to them as partners in their care and treatment. Staff provided positive emotional support to patients.
• Staff felt respected, supported and valued. The trust promoted a culture of openness, transparency, support and learning in a blame free environment, with safety as a top priority. Staff morale across all teams was consistently high.
• Patients could access services when they needed to. The trust had robust and effective bed management processes. With few exceptions, patients could access a local bed and beds were available for patients when they returned from periods of leave. The trust reported low numbers of out of area placements for their acute inpatient and psychiatric intensive care wards. There were no out of area placements reported for the wards for children and young people or wards for older people.
• Staff kept clear records of patients’ care and treatment. Patient confidentiality was maintained. Care and treatment records were clear, up-to-date and available to all staff providing care. The trust provided care and treatment based on national guidance. Staff ensured the needs of different people were taken into account when planning and delivering services. Patients had access to a range of staff with the appropriate skills, experience and knowledge to support care and treatment.
• Staff completed Mental Health Act paperwork correctly. There was administrative support to ensure these records were up to date and regular audits took place. Staff understood and worked within the principals of the Mental Capacity Act. Systems for the safe management and administration of medicine were in place. Incidents and errors within the pharmacies were reported and investigated and outcomes and learning shared with staff.
• The trust had effective bed management processes. We were particularly impressed with recent changes to remove all shared accommodation and reduction in lengths of stay for children and young people within the CAMHS inpatient wards. The trust prioritised reducing the length of time patients spent as inpatients by investing in community teams, home treatment teams and robust care pathways.
• Staff ensured patients had access to opportunities for education and work, including referring patients to a wellbeing college which was delivered in in partnership with the third sector (MIND).
• The trust proactively worked alongside partners to provide joined up healthcare for the local population. Commissioners and other stakeholders confirmed the trust was responsive to challenge and worked collaboratively with stakeholders, other local NHS trusts and the third sector to deliver services to patients. The trust demonstrated a clear priority for involvement of patients, families and carers, which was particularly impressive and demonstrated real involvement.
• The trust’s governance arrangements were proactively reviewed and reflected best practice. The trust had robust systems and process for managing patient safety. Staff recognised when incidents occurred and reported them appropriately. The board had oversight of incidents, and themes and trends were identified and acted upon. Managers investigated incidents appropriately and shared lessons learned with staff in a number of ways. The trust applied the duty of candour appropriately, when things went wrong, staff apologised and gave patients honest information and suitable support. We were particularly impressed with new systems for reviewing incidents, implemented since our last inspection, demonstrating a drive to understand and learn from incidents to improve the safety of services and outcomes for patients.
• We were also impressed by the trust attitude towards innovation and service improvements. The delivery of innovative and evidence based high quality care was central to all aspects of the running of the service. There was a true sense of desire to drive service improvement for the benefit of patients, carers, and the wider system, evident throughout the inspection. Staff included patients in service improvement and used their feedback to change practice. The trust actively sought to participate in national improvement and innovation projects and encouraged all staff to take ownership, put forward ideas and remain involved throughout the process. We saw many examples of innovation and projects that had been trialled and then implemented in the trust.

However:

• Staff working within the older people’s inpatient service were not in receipt of regular, good quality supervision. Where records were available, they were of poor quality.
• We found some environmental concerns that required attention. For example, the assessment room used by the mental health liaison team at Lister Hospital had lightweight furniture and was not soundproof. Two acute wards for adults of working age did not have nurse call bells in patient bedrooms. The health-based place of safety located on Oak unit needed cleaning and some changes to the physical environment. We found some community team bases for children and young people were not clean or well-maintained and in one team, staff did not have access to a suitable alarm system. At one site, there were insufficient rooms available for staff to meet with patients.
• We found some minor concerns related to privacy and dignity and the management of mixed sex accommodation within one older people’s inpatient ward. The trust took immediate action to rectify this. Environmental risk assessments were not always detailed or accurate. Within the community adults’ teams, some interview rooms did not promote privacy and dignity for patients; due to lack of soundproofing. Not all adult community teams had adequate environmental risk assessments in place, particularly in relation to the management of ligature risks.
• On Oak ward, staff did not consistently complete physical observations following administration of rapid tranquilisation in line with the trust policy and National Institute for Health and Care Excellence guidance. Staff did not complete wellbeing care plans for all patients in the community adults service.
• Within some acute wards for adults, there was a lack of psychological therapies as recommended by the National Institute for Health and Care excellence. However, this was due to temporary vacancies and the trust was recruiting psychologists at the time of inspection. Staff assisted patients to access psychological therapies in the community, where possible.
• The trust did not always ensure patients detained under Section 136 of the Mental Health Act were assessed within 24 hours. Between October and December 2018 8% (19 out of 231) of Section 136 detentions exceeded the 24 hours. Out of the 19 cases exceeding 24 hours, staff completed extension forms for 7 detentions. Where delays had occurred, the trust completed incident forms and advised all individuals in writing of the reasons for their delay and follow up actions they could take.
• We found some trust policies had not been reviewed in line with documented timescales.

Updated 2 September 2025

Forest House is a 14-bedded unit that provides specialist inpatient care and treatment for young people living in or outside of Hertfordshire, aged 13 to 18 years. Three of the beds are specifically for young people with eating disorders. The unit is based at Radlett in Hertfordshire and the beds available are for female, male and non-binary gender young people. Forest House accepts both voluntary patients and those who are detained under the Mental Health Act. The unit has a Section 136 suite on site and a de-escalation unit.

There is also a school on site, Forest House Education Centre (FHEC), which is run by the local education authority.
We previously rated the service as requires improvement. Following this assessment, we rated the service as good.

Updated 15 May 2019

The summary for this service appears in the Overall Summary of this report.

Updated 8 September 2015

We rated the Community Learning Disability Services as good because:

• Staff undertook a risk assessment for every person who used the service and this was reviewed regularly. There were excellent lone working policies and all staff followed these to ensure their safety and that of people who used the service.

• Comprehensive personalised and holistic assessments were completed in a timely manner. The team included or had access to the full range of health professionals required to care for the people who used the service.

• Staff were polite, kind and treated people who used the service with respect. People and their relatives told us that staff were compassionate and cared about them. People were actively involved in their care planning and participated in their clinical reviews.

• The teams were able to assess urgent referrals quickly and non-urgent referrals within an acceptable time. Where possible, people had flexibility in the times of appointments. There was easy access to interpreters and signers. People who used the service knew how to complain.

• The team’s objectives reflected the trusts values and objectives. There were good and effective governance systems ensuring good quality and safety. There were opportunities for leadership development. Staff were offered the opportunity to give feedback on services and input into the service development.

Updated 8 September 2015

We rated community-based mental health services for older people as good because:

• The service operated safely, with sufficient numbers of well-trained staff who were aware of, and used, safe practice such as the lone worker policy and procedures.
• The needs of people using the service were assessed and responded to promptly and monitored effectively.
• The teams had a good mix of professionals, nurses, support workers, psychologists, pharmacists, social workers, psychiatrists, occupational therapists, speech and language therapists, who worked together well.
• People using the service were treated with respect and dignity and their individual needs responded to. They were very complimentary about the service and the staff they came into contact with.

• There was a low turnover of staff throughout the services. This offered people using the service consistency and experience.

• Staff were highly motivated, caring and enthusiastic about their work. This was reflected in their contact with people who used the service.
• Changes to the service had been managed effectively, whereby three out of the four areas had relocated services to central ‘hubs’. Staff working in these hubs had responded positively. One area, the North West, was still to move to a hub.

We also noted:

• The environments of some memory clinics were not very welcoming for people using them, and there were delays for some people between being referred and receiving an assessment.
• It was not always clear if people using the service had had mental capacity assessments, which is needed to ensure people are not given treatment they are unable to consent to.

Updated 15 May 2019

The summary for this service appears in the Overall Summary of this report.

Updated 25 April 2018

The summary for this service appears in the overall summary of this report.

Updated 26 May 2023

Warren Court is part of the Eric Shepherd Unit and provides medium secure assessment and treatment services for men with learning disabilities, additional mental health needs and a history of offending. The service is run by Hertfordshire Partnership NHS Foundation Trust. The other three locations from which care is delivered within the forensic services are Broadland Clinic, Beech Unit and 4 Bowlers Green.

We carried out an urgent, unannounced inspection of Warren Court because we received concerns about the safety and quality of the services and whistleblowing concerns in relation to the culture of the service.

During this inspection we looked at all of the key questions of services safe, caring, and well-led.

We did not look at the key questions of effective or responsive. Therefore, these ratings remain in place with both core services rated as good.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support: Model of Care and setting that maximises people’s choice, control, and independence.

This service is a medium secure provision which means that there are certain restrictions in place regarding choice, control, and independence. Measures were in place to maximise choice for people within these restrictions. However, people did say they were bored at times and had limited choices of activity.

Right Care: Care is person-centred and promotes people’s dignity, privacy, and human rights.

People received kind and compassionate care from staff who protected and respected their privacy and dignity and understood each person’s individual needs. People had their communication needs met and information was shared in a way that could be understood.

Right Culture

The ethos, values, attitudes and behaviours of leaders and staff ensure that people using the service lead inclusive and empowered lives.

The needs and safety of people form the basis of the culture at the service. Staff understand their role in making sure that people are always put first.

We rated safe as requires improvement, caring as good and well led as good.

The overall rating is now good.

We rated this service as good because:

The service managers had re-instated the carers forum in October 2022 to introduce a way for carers to communicate and feedback about the service.

Most staff understood their roles and responsibilities under the Human Rights Act 1998, Equality Act 2010, and the Mental Capacity Act 2005.

The trust provided information that showed 89% of staff had received supervision, although three staff members told us the process to access supervision was not clear.

The team Leaders and clinical managers were visible and supported staff when staff shortages occurred. Staff told us that clinical managers and team leaders were supportive.

Peoples’ care plans and risk assessments were updated at the fortnightly multi- disciplinary (MDT) meeting which all members of the MDT attended.

The furniture on the houses was safe and appropriate for the individual’s needs.

However:

The environment in House 5 required redecoration and did not provide a therapeutic environment. There were very few pictures or information notices available on the notice boards for people who use the service, with no easy read format on display.

Staff did not always engage people in meaningful activities and people using the service told us they were often bored as there was a lack of activities and staff were too busy doing other things to spend time with them.

Staff had not completed positive behavioural support plans for all people using the services, and although people were kept safe, staff did not always understand some people’s holistic needs or respond to those needs in a timely manner. We found that only one person had a positive behavioural support (PBS) plan and the person had not been involved in developing the plan. This did not detail an overall holistic approach to the person’s care or give staff a clear understanding of how they might support the person’s needs and mainly described how any challenging behaviours should be managed. Staff had not received training in how to implement positive behavioural support (PBS) plans. People being cared for were not involved in developing the plans.

The service did not display information in all communal areas about how people could access advocacy and other local services. They also did not display information on how people could make a complaint should they wish to.

On all three houses staff did not monitor the temperature of the clinic rooms or medication fridges consistently so were unaware of whether medicines requiring refrigeration were being kept at the correct temperature to ensure their efficacy.

Updated 8 September 2015

We gave an overall rating for long stay/rehabilitation wards of good because:

We found that the wards were kept clean and well maintained and patients told us that they felt safe. There were enough, suitably qualified and trained staff to provide care to a good standard. At Sovereign House, one qualified and one unqualified staff worked each shift; at The Beacon, two qualified and two unqualified staff worked each shift and at Gainsford House and Hampden House, two qualified and one unqualified staff worked each shift. We found that patients’ risk assessments and formulations were robust and person centred. We found the service had strong mechanisms in place to report incidents and we saw evidence that the service learnt from when things had gone wrong. We found, however, that patients were not protected against the risks associated with the unsafe use and management of medicines. This related to the rehabilitation wards not having appropriate arrangements in place for obtaining, recording, and dispensing medicines.

The assessment of patients’ needs and the planning of their care was individualised and had a focus on recovery. We found staff had a good understanding of the Mental Health Act 1983 (MHA), the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS) and the associated Codes of Practice. We saw throughout all of the wards that the multi-disciplinary teams were involved in assessing and delivering patient care. We found motivated and supportive ancillary staff on all of the wards.

We found caring and motivated staff, and, saw good, professional and respectful interactions between staff and patients during our inspection. Patients commented positively about how kind the staff were towards them. We saw evidence of initiatives implemented to involve patients in their care and treatment. These included the recovery STAR tool and daily ward briefings with all patients and staff.

We found bed management processes were effective. Patients were able to access a rehabilitation bed when required and were actively engaged, through a recovery focussed model of care, to prepare for community living. We found a developing service model and care pathway which optimised patients’ recovery, comfort and dignity. We found a varied, strong and recovery orientated programme of therapeutic activities, many of which were making use of the local mainstream, community facilities. These included many community based sporting activities, as well as person centred interpersonal skills training. We noted the service was responsive to listening to concerns or ideas made by patients and their relatives to improve services.

We found all staff to have good morale and that they felt well supported and engaged with a visible and strong leadership team which included both clinicians and managers. We found governance structures were clear, well documented, adhered to by all of the wards and reported accurately. We noted a quality initiative called, “show casing” which identified a particular area of the service where a development or improvement had been identified. This was then advertised and celebrated across the rehabilitation service and the rest of the trust. We saw that this particularly motivated staff and gave them impetus to continue to improve the quality of care and treatment provided.

Updated 15 May 2019

The summary for this service appears in the Overall Summary of this report.

Updated 26 May 2023

We carried out this unannounced focused inspection because we received information giving us concerns about patient safety and quality of the service on Oak Unit.

This was a focused inspection, looking only at Oak Unit, the psychiatric intensive care unit.

Our rating of this service stayed the same and was rated as good. Our rating of safe went down from good to requires improvement. That is because we found breaches of regulations and issued Requirement Notices telling the service provider what it must improve.

In these circumstances the rating linked to the area of the breach is normally limited to requires improvement.

(See the Areas for improvement section for more information.)

• See our website for more information about our Ratings principles

This report describes our judgement of the quality of care at this location. It is based on a combination of what we found when we inspected and a review of all information available to CQC, including information given to us from patients and the public. For this inspection, we looked at the safe and caring domain.

Hertfordshire Partnership University NHS Foundation Trust provides acute wards for adults of working age and psychiatric intensive care across six wards, over three sites. Oak Unit is a 12 bedded, male only, psychiatric intensive care unit (PICU), which is housed in a purpose-built premises at Kingsley Green, Radlett. The unit provides care and treatment for patients who are experiencing an intense period of mental distress and are very unwell. There were 11 patients admitted to the unit when we carried out this inspection, one of whom was on leave away from the ward. All patients on Oak Unit were detained under The Mental Health Act 1983.

The Acute wards for adults of working age and psychiatric intensive care units service was last inspected in March 2019, when it was rated good.

During this inspection we found:

• The ward used regular bank and agency staff to cover vacancies, which meant there were enough staff deployed on the unit.
• Staff carried out regular safety audits of the environment.
• The ward layout was deemed to be safe and risks were well managed.
• Staff understood how to protect patients from abuse.
• Staff were generally discreet, respectful, and responsive when caring for patients. We observed a number of positive interactions between staff and patients.
• Patient care records showed that staff made sure patients understood their care and treatment and found ways to communicate with patients who had communication difficulties.
• Staff were supporting one patient to develop and display some artwork on the ward.
• Patients had easy access to an independent advocate, who visited regularly.

However:

• Staff were regularly required to carry out continuous patient observations for longer than the recommended time of two hours, some without being allocated a break.
• Not all staff had easy access to clinical information, and it was not easy for them to maintain high quality clinical records.
• Staff turnover, vacancy rates and sickness levels were high.
• The temperature on the ward was uncomfortably hot and could not easily be adjusted by staff. However, there were plans in place to mitigate this.

How we carried out the inspection

This inspection was unannounced, meaning the provider did not have advanced notice of the inspection.

The inspection team visited Oak Unit on 18 and 19 October 2022. We further visited on 31 October 2022.

During the inspection we:

• visited the ward and observed how staff cared for patients
• toured the clinical environments, including the clinic room and reviewed emergency equipment
• reviewed three patient care records
• spoke with seven patients
• spoke with two carers
• spoke with the independent advocate
• carried out a variety of observations on the ward including serving of lunch, ward based activities and a group cookery session
• reviewed how staff managed patient safety incidents by examining CCTV footage and incident paperwork
• observed one staff handover
• interviewed five staff including nurses, nursing assistants and a ward manager
• reviewed patient observation records, staffing rotas and patient observation allocation sheets and minutes of recent patient “mutual help” meetings
• reviewed data supplied by the trust, documents, policies and procedures relevant to the running of the service.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection

What people who use the service say

We spoke with seven patients and two family carers, and we reviewed one written compliment. Patients gave us mixed views about how they experienced the care and treatment they received.

All but one patient told us there were enough staff on the ward. Three patients told us they felt safe and supported by staff. However, three patients told us they did not always feel safe on the ward because some patients were threatening and had been physically aggressive, assaulting them or others. One said they felt unsafe by the practice of physical restraint, because they found the experience abusive and degrading, but noted that “98% of staff are respectful”. However, another patient told us they had experienced physical restraint and “staff were always gentle”. Two patients told us they had raised their concerns with staff about not feeling safe but had not received suitable assurances. One said staff had not responded helpfully and the other told us that they had not any feedback since they raised the issue. However, another patient told us “everything I’ve raised has been dealt with”.

Two patients told us that while there were always enough staff on the ward, a lot of them were carrying out safe and supportive observation duties, so when patients asked them for something, they were not able to help with their query or request. However, if staff were available, they could speak to them about their feelings. One patient told us that staff were “great, amazing and incredible”. The minutes we reviewed from a sample of the patient “mutual help” meetings, showed numerous positive “thank you” comments from patients to staff.

One patient told us they became agitated when the lounge was noisy and overcrowded. Another said the ward was so noisy, they couldn’t hear their telephone conversations. Patients on Oak Ward have access to a quiet lounge and their bedrooms. If the ward environment is over stimulating, patients can be supported to access these areas.

One patient told us if they bought vaping machines from the trust, that they costed almost double the price that they could buy them for in the community. They felt this was unfair. Another told us if the machine on the ward where they bought vapes was empty and this caused “tensions to rise”. Another they also told us the times set for patients to be able to go outside and use their vaping machine coincided with a staff handover meeting, which meant there were not always enough staff to support them to use their vapes at the time they were scheduled to use them. They said this was frustrating and it made them angry.

One patient told us that staff were not always consistent in their responses, indicating some were more boundaried in their approach than others. They also told us that some overseas staff were unwilling to talk to patients about their sexuality and often spoke to each other in a language the patients didn't understand. Another patient told us that some situations with other patients “escalate unnecessarily," because “staff don’t listen to patients and resolve things quickly”.

Some patients told us there were lots of activities for them to participate in, such as art and craft, playing music, chess games with the occupational therapist, a smoothie making group, cooking sessions, a walking group and using the gym. However, others told us there were not enough activities, and they were bored. All the patients told us they could go outside for fresh air, but some noted there was no shelter for them to use while vaping, so they could be cold and wet. A separate outside area, the courtyard, which had a shelter was being refurbished and not accessible to patients. Patients had monthly Mutual Help Meetings, where they could discuss issues with staff. At these meetings, they were able to request additional activities, such as board games, access to specific PlayStation games or devices to access social media. These would then be taken forward for a multidisciplinary team meeting for a review to the appropriateness of the requests and actioned if deemed appropriate.

Family carers told us they were often kept waiting for between 30 minutes and an hour before their relative was brought to see them for their arranged visits. They felt this was too long to be kept waiting. They told us they were not as not fully involved in their relative’s care as they would have liked to have been and were not given opportunities to provide feedback about the service or given information about how to make a complaint if they were unhappy with the service. One family carer told us that their relative felt there were not enough staff on the ward and the ward round meeting that they were invited to attend was set at a fixed time on the same day every week, which was inflexible.

Updated 15 May 2019

The summary for this service appears in the Overall Summary of this report.