Hertfordshire Partnership University NHS Foundation Trust

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that young people were protected from abuse and avoidable harm. At our last assessment we rated this key question as requires improvement. At this assessment the rating has changed to good. This meant young people were safe and protected from avoidable harm.

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.

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.

The clinical team had identified a number of safety initiatives following learning from incidents. These had been put in place leading to a reduction in incidents.
Initiatives included:
• embedded Trauma-Informed Approaches across the whole staff team
• increased awareness of Neurodivergence and Learning Disability, leading to wider implementation of Reasonable Adjustments
• rolling out the Clear Unit Programme, with OT-led activities and increased engagement
• increased support from the Reducing Restrictive Practice Nurse, with reflective learning sessions.

Staff demonstrated confidence in raising concerns and reporting incidents. Safety events were routinely reviewed through patient safety incident response framework (PSIRF) processes, including structured whole system analysis of risk and mitigations (SWARM), which were well attended by the multidisciplinary team and senior leaders.

Learning from incidents was systematically identified and shared through a range of forums, including staff meetings, reflective forums and bite-sized learning sessions. Actions arising from incidents were clearly tracked and reviewed.

For example, a SWARM was convened following an incident where a young person went absent without leave (AWOL) and was returned to the unit by police. The review identified system-level contributory factors, including communication breakdowns across shifts, documentation gaps, variability in staff perception of risk and staffing pressures. Learning from this review led to clear improvements, including the introduction of a pre-leave risk assessment template, strengthened liaison with the police by development of a police passport, clearer escalation pathways including promotion of utilising out-of-hours clinical lead support, and improved integration of safety planning into the multidisciplinary team (MDT) and ward round discussions.

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.

Clear clinical, operational and safeguarding pathways were in place. These included an established process for admission, risk assessment, observation, physical health monitoring, medication management, safeguarding, restrictive practice oversight, long-term segregation (LTS) and hospital-to-home transitions.

Safety systems were proactively monitored through a comprehensive layer of audits, including ‘Fundamentals of care’, ligature audits, food and fluid monitoring, physical health assessments, care planning, patient rights, observation quality and medication safety. Audit findings were reviewed at multiple levels, with clear action planning where required.

The provider’s pathways were responsive to the needs of a highly complex cohort, including young people with eating disorders, neurodivergence and young people who engage in headbanging. For example, the service had introduced a protocol specifically for managing the risks associated with headbanging. The service was also in the process of drafting a nasogastric tube (NGT) feed pathway, recognising the need to adapt to changes in clinical needs of the young people accessing the service.

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.

Safeguarding was treated as a shared responsibility across different staffing networks. All safeguarding concerns identified by the service were shared promptly with relevant social care networks. There was clear evidence of timely and proportionate multi-agency working, including an in-house consultant social worker who would be involved in care planning, risk management and discharge planning, where appropriate.

Safeguarding was a mandatory training requirement for staff. During the assessment period, 4 staff were showing non-compliant however 1 staff member had left and 1 was off the unit on placement. The 2 remaining staff were newly qualified and in supernumerary induction with dates booked to undertake training.

The service had a robust safeguarding children policy in place which covered areas such as the Mental Capacity Act and Gillick competency.

The service demonstrated a strong oversight of safeguarding themes and trends. Incidents were monitored and reviewed, with recognition that at least 50% of young people were already known to social care at the point of admission.

Young people told us they felt safe on the ward and understood how to access support if they felt unsafe or distressed. Staff supported young people to understand risks and respond to changes in their emotional or mental health, and young people described knowing who to speak to when they needed help. Risk management was generally approached holistically, particularly in the ward rounds, considering young people’s psychosocial needs.

Young people reported receiving information about their treatment, including medication, during ward rounds and felt involved in decisions about their care. Both young people and their carers spoke positively about the involvement they had in care planning and risk management during ward rounds. There are also process in place to keep families informed of care and treatment plans.

However, young people’s experiences of involvement in nursing care plans were mixed. Some young people reported limited involvement, for example:
“I don’t think I was involved in the making of my care plan”
“I have a care plan but I have no involvement in it”
Others described partial involvement, saying:
“I have a care plan and have had some involvement”
“I have a care plan, I was involved a little”

Carers described being informed about the ward and their child’s care and treatment, and 1 carer said they were involved in decisions about leave arrangements in relation to risk management. However, 1 carer said that they were not informed when their child had been restrained and given medication over the weekend.

The provider was fully aware of all potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Where improvements were required, the provider was in the process of addressing these areas.

The unit was mixed gender, with bedroom allocation arranged to separate females and males at opposite ends of the dormitory corridor. All the bedrooms had an ensuite available.

There were effective systems in place to identify, monitor and manage environmental risks. Ligature risk audits were completed annually and weekly, with actions clearly recorded and tracked to completion. Identified risks were managed through environmental checks, observation levels and individual risk assessments.

Personal alarms and nurse call bell systems were in place and routinely monitored. A daily log of personal alarms was issued to staff, and staff were required to test alarms prior to use.

All of the young people we spoke to reported feeling safe on the ward. The young people have access to a quiet lounge, a main TV lounge and their bedrooms if required. However, some feedback highlighted environmental factors that could impact psychological safety. Young people described the ward as loud, with 1 young person stating, “there is nowhere to relax”. One carer reported that their child found the ward environment noisy. Whilst the environment was physically safe, it did not always meet young people’s sensory needs.

However, the provider was actively working towards improving the sensory aspects of the environment. Planned and ongoing environmental modifications, such as the development of a silent alarm systems and a bespoke sensory room which is now completed and awaiting commissioning, demonstrated a commitment to creating a space that reduces distress. The provider was also in the process of obtaining ward accreditation from the National Autistic Society to create an environment that reduced sensory overwhelm.

The provider had systems in place to ensure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development.

The provider had a clearly defined staffing establishment, set using the mental health optimal staffing tool (MHOST) which was ratified by the trust board. Staffing levels and skill mix were actively monitored in relation to acuity and risk, and senior leaders maintained oversight of staffing pressures. Workforce data showed a negative vacancy rate (-2.0%), indicating the service was over establishment at the time of review. While turnover for October 2025 was 14% and sickness levels were 9.4%, which the provider recognised as contributing to staffing pressure at weekends and during periods of increased demand, these challenges were consistent with wider national workforce pressures. The service had not used agency staff since August 2025, providing continuity and stability for young people. Mandatory training compliance was 92.6% in October 2025 and where gaps were identified the provider had a robust action plan in place.

Some carers and young people described the impact of staffing pressures at specific times. One carer told us that at weekends, “bank staff lack some training and don’t understand patients”, and that on one occasion their child’s leave had been cancelled due to staffing levels. One young person also stated that leave cancellations sometimes occurred, stating “it does happen if not enough staff”.We identified 1 occasion where a young person could not attend the on-site school due to staffing issues, and 1 report through learning from patient safety events (LPFSE) in November 2025 highlighted unsafe staffing levels. These episodes were limited in number and the provider demonstrated awareness of these risks.

Staff told us that staffing pressures could increase when a young person was being supported within a Section 136 suite at the same time as ward rounds were taking place, which placed additional demand on nursing capacity. The provider explained that the Section 136 suite nursing establishment included 1 registered nurse and one healthcare assistant, which was built into the units overall nursing establishment.

Senior leaders described a dynamic and responsive approach to staffing oversight, including shift-by-shift daily reviews and weekly roster checks to ensure staffing remained responsive to acuity and risk. The staffing establishment was also subject to biannual peer review, providing additional assurance regarding workforce planning and safety. The provider also demonstrated planned mitigation, including senior nurses stepping onto shifts, substantive staff working bank duties and support from the wider multidisciplinary team.

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

There were effective systems in place to prevent, identify and manage the risk of infection. Monthly inpatient audits demonstrated high levels of compliance with local hand hygiene, decontamination and sharps safety protocols. There was adequate supply of personal protective equipment (PPE). These audits were routinely completed and reviewed, providing assurance that infection prevention control (IPC) standards were embedded into daily practice.

Staff received mandatory IPC training appropriate to their role. The ward environment was visibly clean. Whilst 1 young person said that the bathrooms were “not very nice”, other young people and carers reported that the ward was clean and tidy.

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.

Young people were involved in decisions about their medicines. Young people told us that medication was routinely discussed during ward rounds, and they were given explanations about why medicines were prescribed or changed.

Medicines were prescribed and administered using an electronic prescribing and medicines administration system (ePMA). Where ePMA-related issues were identified, these were recognised as trust-wide risks and addressed through system improvements, training and strengthened admission processes.

Medicines were appropriately prescribed, supplied and administered in line with relevant legislation and national guidance, including the Mental Capacity Act.

There were arrangements in place to ensure that accurate and up-to-date medicines information was available. Pharmacy oversight and ePMA records supported medicines safety.

Medication was used appropriately, in line with trauma-informed perspectives, not to control behaviour. There was clear emphasis on proportionality and least restrictive practice.