Hertfordshire Partnership University 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

Safe – 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 improved to outstanding. This meant people were protected by a strong and distinctive approach to safeguarding, including positive risk-taking to maximise their control over their lives. People were fully involved, and the provider was open and transparent when things went wrong.

This service scored 88 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 4. The evidence showed an exceptional standard. The provider had a strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

Staff reported serious incidents clearly and in line with trust policy. Staff recorded incidents on an electronic incident reporting system. Managers produced a detailed monthly report which provided a monthly update on the safety data and workstreams, including a comprehensive narrative which explored any increases in incidents or areas for improvement.

In the 3 months leading up to inspection, across all 3 wards, the trust reported 53 incidents including actual assaults against staff, 232 incidents involving violence and aggressive behaviours to staff and 53 incidences of self-harm. Headbanging was the most prevalent self-harm behaviour. Individualised care plans and positive behaviour support (PBS) plans were in place,and the headbanging post-incident protocol was routinely used. Patients received support and debriefs following incidents.

Managers investigated serious incidents thoroughly using the ‘Patient Safety Incidence Response Framework (PSIRF)’, including reviewing closed-circuit television (CCTV) footage, where this were available, to identify areas of improvement and good practice. Service Line Leads, Modern Matrons, Team Leaders and Medical Leads had key roles in identifying incidents that required further incident and/or thematic analysis and for ensuring proportionate action was taken.Within the trust, management of the PSIRF process was the responsibility of the Head of Safer Care and Standards who reported to the Deputy Director of Safety and Risk Management. The trust also had an additional Organisational Safety Lead who supported and led on elements of the Trust's safety strategy and reducing restrictive practices programs and co-coordinating best practices.

Staff received exceptional support after serious incidents. Staff told us they always had time allocated away from the ward after every shift for reflection and to talk through any concerns or incidents that had occurred on that shift before they went home. Psychology staff offered hot and cold debriefs, training and facilitated reflective practice sessions for staff from different wards to the ones where they usually worked. This allowed staff to speak openly with a facilitator who they didn’t work with everyday and who could offer an external perspective.

Staff received feedback from investigation of incidents, both internal and external to the trust. For example, staff told us of how they had changed their practice on the wards following a national safety alert regarding the risks of plastic bags. Learning from incidents was discussed in monthly Quality and Risk meetings, staff meetings, supervisions, handovers and shared in e-mails.

Managers identified from incident records and staff reports that racist language was being used by patients on the wards which was affecting staff wellbeing. Following this, an action plan was created. This included an educational programme for patients and staff, culture celebration days and enhanced staff support. Education staff worked with patients to complement this project, including encouraging patients to learn about different countries and cultures, colouring in maps and flags (which we saw displayed on patient’s bedroom doors), cooking foods from different countries and listening to international music. At the time of inspection, the program was ongoing with plans for evaluation and sustainability.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if things went wrong. The trust had a duty of candour policy which gave additional information on the trust’s standards and expectations in relation to the duty of candour.

We scored the service as 4. The evidence showed an exceptional standard.The provider always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always 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. Patients were admitted from residential care, supported living, the family home or emergency departments.

Staff made sure they shared clear information about patients and any changes in their care, including during handover meetings. Staff held handover meetings at the end of each shift.

Teams had effective working relationships with external teams and organisations. Our review of records from Multi-Disciplinary Team (MDT) meetings and care records indicated involvement of family members, key stakeholders, and care teams in discussing patient progress, future care planning, transitions and discharges. We saw clear partnership working documented at ward reviews.

The trust responded to the national Transforming Care Agenda review - an NHS-led initiative designed to improve the lives of people with learning disabilities and/or autism, particularly those with complex mental health conditions or behaviours that challenge. It focuses on reducing reliance on in-patient hospital care, closing inappropriate facilities, and enhancing community-based, personalised support. The trust introduced community teams - the intensive support teams (ISTs) – these were based in community teams within Essex and Hertfordshire and based on the ward at Astley Court in Norfolk. The teams provided intensive support to patients in the community, prevented admissions to hospital wherever possible, and facilitated early discharge. When a patient was admitted, community and ward staff worked closely to ensure comprehensive information sharing and risk assessment. IST staff regularly visited their patients on the wards to provide reassurance and continuity of care.

The consultant psychiatrists worked across the community and inpatient wards – they told us this fluidity ensured safe and effective care, including out of hours cover and support. A staff member from the community IST told us, ‘It is amazing to be able to continue to have seamless contact with people admitted to the ward….it makes transitions a lot easier – information and shared care can be planned, and all staff have access to all relevant information’.

The trust worked with commissioners and social care in each area on local Dynamic Support Registers (DSR) - a tool designed to identify and support people with learning disabilities or autism who were at risk of unnecessary hospital admission.This ensured individuals received appropriate community-based care, prevented crisis situations, and aligned with national "homes, not hospitals" policies.

We received positive feedback regarding hospital systems, pathways, patient flow, safety and quality from commissioners and other stakeholders. For example, one commissioner fed back that ward staff provided thorough transition plans and continued to work with staff at patients’ ongoing placements and/or families after discharge. Another external stakeholder fed back ‘how well planned, thorough and supportive the transition process had been’ for their patient.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. We looked at 9 care records and saw all patients had a comprehensive discharge plan and if there was a delayed discharge, the reason was documented and any actions being taken to address this.

We scored the service as 3. The evidence showed a good standard. The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff 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 provider shared concerns quickly and appropriately.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. At the time of inspection, the compliance rate for mandatorySafeguarding Adults and Children training ranged from 80 – 100%.

The trust had a Safeguarding policy which included clear processes and flow-charts to support staff in recognising abuse and making a safeguarding referral when appropriate and staff kept safeguarding logs. Staff reported 14 safeguarding-related incidents between October and December 2025. Safeguarding concerns related to a variety of incidents including violence and aggression towards peers, falls and disclosure of risk of historical sexual exploitation. In line with Trust safeguarding processes and protocols, timely external referrals were submitted to the relevant local authority safeguarding teams and social services to ensure appropriate multi-agency oversight and support.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. For example, a member of staff told us about how they kept patients safe who may be at risk of sexual safety incidents due to vulnerability to unwanted sexual contact and lack of capacity to consent.

Staff followed clear procedures to keep children visiting the ward safe. Children were not permitted to visit patients on the wards. Visits from children took place at other areas in the hospital.

All the patients and carers we spoke with told us they, or their loved one, felt safe on the wards.

We scored the service as 4. The evidence showed an exceptional standard.The provider always worked well with people to fully understand and manage risks by thinking holistically. Staff provided care that fully met people’s needs and was safe, supportive and enabled people to do the things that mattered to them.

Staff knew patients well and were aware of any risks they posed to themselves, to each other or to the environment. Staff knew what strategies to use to minimise and manage risks. For example, for a patient who was frail and at risk of falls, occupational therapy staff installed movement sensor lights in her bedroom to support her with additional light if she chose to get out of bed during the night.

Staff developed positive behaviour support plans (PBS) for patients to equip staff with strategies to recognise when a patient was becoming distressed and to know how they could best support patients in these situations. APBS planisa person-centred, proactive strategy to understand and manage distressed behaviours, focusing on improving quality of life for individuals with learning disabilities or autism. We saw that all patients had individualised PBS plans as well as sensory ladders which isa personalised, visual, and educational tool that helps adults with learning disabilities understand, communicate, and manage their internal arousal levels. Staff had recently undertaken a PBS Strategy Project to identify how the trust could improve the PBS services that were provided across the service. The key recommendations of the PBS Strategy were presented to managers in December 2025 and were due to be launched and rolled out during 2026. 

Staff had recognised the needs of female patients during the menopause and had incorporated menopause related considerations into patients’ risk assessments to reflect menopause as a potential factor affecting an individual’s presentation, behaviours or risks.

Staff communicated with patients so that they understood their care and treatment, finding effective ways to communicate with patients using easy read materials, choice boards, pictorial aids and social stories. We saw an example where staff had explored ways to communicate with a patient, including using easy read materials, to explain the effects of the menopause and the benefits of hormone replacement therapy (HRT). The patient disliked HRT patches; alternatives were discussed, and they agreed to try HRT gel and tablets, which they were happy with.

Staff ensured that patients and carers could access advocacy. The service had independent advocates who visited the wards regularly. There were easy read poster displayed on the wards with information and photographs of the advocates who would be attending, along with contact information.

The trust had a ‘Blanket Restrictions Policy’ which outlined the roles and responsibilities of all staff to recognise that blanket restrictions (restrictions that applied to all patients on a ward) could be a violation of an individual’s human rights and to ensure that blanket restrictions were avoided unless they were a necessary and proportionate response to an identified risk. Staff told us they used restrictive practice, including blanket restrictions, as a last resort and were open to challenge about these restrictions from patients, staff, family members or other stakeholders.

The trust had a reducing restrictive practice lead, staff attended a monthly restrictive practice group and produced a division report for the trust restrictive practice committee. At the time of inspection, there was a blanket restriction at Lexden Hospital as the door to the garden and courtyard was kept locked. This was due to the area being out of eyesight and needing to be a supported area to maintain patient safety. However, a project group had been set up to review ligature risks and risk reduction to ensure safe accessibility. All patient care plans reflected the individual need and risk for each patient accessing these areas.

Staff collaborated with patients and families in a positive risk-taking approach to empower patients and foster autonomy and independence while managing potential harms. For example, staff worked together to enable a patient, who was supported in long-term segregation due to potential risks to herself and others while distressed, to regularly go out into the community. We saw that she had recently been to the zoo, for a spa day and for a meal in a restaurant followed by a tribute concert for her favourite singer.

The trust had a ‘Positive Steps Together - Embedding Safety Framework for Assessment and Treatment Units’project which identified that building trusting and positive relationships with service users, families and the wider system was an essentialcomponentfor embedding safety.The framework identified actions for staff, patients and families across 6 domains, including positive relationships, timely debriefs, effective handovers, purposeful days and safety huddles.

In the 3 months prior to the inspection the provider reported 80 incidents involving restraint. Incident numbers were highest at Astley Court with most incidents being attributed to 2 patients who had displayed a high level of distress and were resistive to attempts to use de-escalation techniques. There were no incidences of restraint on Elm ward in November and December. The provider reported 0 episodes of the use of rapid tranquilisation in the 3 months prior to inspection. No incidents involved prone, face down restraints. There were no incidents of seclusion. At the time of inspection, 2 patients were supported in long term segregation – 1 at Lexden Hospital and 1 at Astley Court.

Staff made every attempt to avoid using restraint by using de-escalation techniques and restrained patients only when these failed and when necessary to keep the patient or others safe. Staff completed training in the use of restrictive interventions. Staff we spoke to were able to tell us about the various de-escalation techniques they would use such as verbal de-escalation and utilising a low stimulus environment or distraction. We saw an example in a care plan where there was a clear de-escalation approach documented following an episode of distress.

Staff reported and monitored all sexual safety incidents and incidents of racial abuse, and these were discussed at the monthly division safety group meetings and quality and risk meetings. Staff, including education and occupational therapy staff, worked with patients to support them with boundaries, consent, sexual health and developing healthy relationships. The Trust had developed sexual safety training which was being rolled out to all staff.

When incidents occurred, staff responded promptly, documented incidents accurately, and updated care plans and risk assessments. All the staff we spoke with knew what incidents to report and how to report them.

We scored the service as 3. The evidence showed a good standard. The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

During the inspection visit, we toured all the wards. We observed the wards were clean and well decorated and maintained. Elm ward was a newly opened and refurbished ward – patients had recently moved there from a different ward at the site. The design and decoration of Elm Ward had been completed in co-production with patients and families and was a particularly pleasant environment.

Staff could not observe patients in all parts of the wards and outside space. However, the service had fitted convex mirrors and closed-circuit television to monitor communal areas and used enhanced observations to support patients with additional risks

All wards had ‘Patient Safety at a Glance’ interactive whiteboards in nursing offices which clearly displayed real-time information about each patient including, risks, observation levels, key-workers, section 17 leave, allergies etc.

The ward complied with guidance on mixed sex accommodation. There were separate male and female corridors on all the wards including separate male and female lounges and bathrooms.

Staff knew about any potential ligature anchor points and mitigated the risks to keep patients safe. Staff completed weekly ligature audits to identify any new ligature risks within the environment. We saw an example where a member of staff had identified a window that was broken and not shutting properly which was escalated for urgent repair.

Staff had easy access to alarms and patients had easy access to nurse call systems. Elm Ward used Silent Alarm System (SAS) alarms to minimise sensory impact, reducing distress associated with loud or sudden noises whilemaintainingthe safety of service users and staff.

Clinic rooms were clean and fully equipped, with accessible resuscitation equipment and emergency drugs that staff checked regularly.

Seclusion rooms were clean and complied with the MHA Code of Practice.

Each patient had their own bedroom which they could personalise. All the bedrooms on Elm ward were painted with individual, distinctive colours, had full-length mirrors, televisions, desks and comfortable seating. Patients had photos on their bedroom doors depicting their favourite animals or hobbies and the names of their key staff. All bedrooms on Astley Court and Elm ward had ensuite bathroom facilities. At Lexden Hospital, not all the bedrooms were ensuite. However, all patients had sinks in their rooms and there were sufficient male and female showers and bathrooms, so patients did not have to wait if they wanted to use one.

Patients had a secure place to store personal possessions.

Staff used a full range of rooms and equipment to support treatment and care. The wards had clinic rooms, 1-1 meeting rooms, sensory rooms, quiet lounges and low-stimulus areas. There were also classrooms and rooms for group work, occupational therapy and activities. At Elm Ward, there was a gym and cafeteria available for patients to use on the main hospital site.

The service displayed the names and photos of all staff on each ward, so that staff and visitors were aware of the staff working on the wards.

We scored the service as 3. The evidence showed a good standard. The provider 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, the overall vacancy ratefor all 3 wards combinedwas 9%.Vacancies were mainly for registered nurses where recruitment had been challenging despitenumerousrecruitment drives; with the trust competing for staff who could work in London and achieve a higher salary due to London weighting.The trust had therefore,over-recruited toband 5 posts with the introduction of Band 5 to Band 6 development posts. There had also been a slight increaseto band 6 establishment with the moveto Elmto support clinical meetings and ward leadership.

During our visits, we could see the wards were fully staffed and people told us there were always enough staff on the wards. The trust no longer used agency staff and used regular bank staff who knew patients well to cover for vacancies, annual leave and sickness.

At the time of inspection, the sickness rate was 6.3%. The overall turnover rate was 6.7%.

There were enough staff to carry out physical interventions and observations safely and staff had been trained to do so.

There was adequate medical cover day and night and a doctor could attend quickly in an emergency. The service had a 24 hour on call rota for staff to access support when needed.

Staff had received and were up to date with appropriate mandatory training. The overall training compliance was 94%. The mandatory training programme was comprehensive and met the needs of patients and staff.

The training was appropriate for the patient group using the service. The trust offered staff a programme of learning disability specific training, for example, Trauma-informed Care, Personality Disorder and Learning Disability, Dysphagia, Makaton, Epilepsy, and Menopause and Learning Disability. All staff had completed the Tier 1 Oliver McGowan mandatory training on Learning Disability and Autism (for a general awareness of the needs of autistic people and people with a learning disability).

Healthcare assistants (HCAs) were provided opportunities to input into the development of care plans and leave plans and HCAs told us their input was valued and considered. HCAs were also invited to attend clinical review meetings, alongside MDT, families and patients. These opportunities ensured that staff were equipped to develop and progress within their roles.

On Elm ward, a consultant psychologist offered monthly Adaptive Mentalization Based Integrative Treatment (AMBIT) sessions to staff. AMBIT is a framework designed to help teams create effective systems of care and was developed to support workers who work with clients with multiple needs. It encourages equal attention to how teams work effectively with complexity, how colleagues support and reflect on each other’s practice, how services build strong multi-agency relationships, and how teams continuously learn and adapt their approaches.

Managers monitored mandatory training and alerted staff when they needed to update their training. Managers received a regular report showing compliance with mandatory training. This report included details of training that was soon to expire.

Managers gave each new member of staff a full induction to the service before they started work.

We scored the service as 3. The evidence showed a good standard. 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.

Staff maintained equipment well and kept it clean. All ward areas were clean, had good furnishings and were well-maintained.

Staff followed infection control policy (IPC), including handwashing. Masks and hand gel were available, and staff followed personal protective equipment guidelines.

Matrons undertook a monthly IPC walkabout, and staff undertook monthly infection control and prevention audits. This included checking hand hygiene, decontamination of medical equipment, catheter care and sharps safety. We viewed audits that showed staff had mostly 100% compliance in all areas. At the time of inspection, 100% of staff had completed training in Level 1 infection prevention and control.

We scored the service as 4. The evidence showed an exceptional standard. The provider always made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff always involved people in planning, including when changes happened.

Medicines were available across all three sites, including controlled drugs (CDs), and were stored securely, with appropriate temperature monitoring, and access was restricted to authorised staff. CD balances were accurate, and we saw evidence that quarterly audits were undertaken. Emergency medicines were available and checked regularly.

Staff told us the pharmacy team could be contacted when not on site, and staff had mechanisms in place to be able to access medicines out of hours. Upon admission, there was a process to reconcile medication (the process of gathering accurate information about a person’s prescribed medicines).

Medicines were prescribed and administered using an electronic system, and people received their medicines as prescribed. All patients had the correct consent to treatment forms easily accessible at the point of administration. Where people refused their medicines, strategies were in place to encourage adherence. If doses were omitted, there were systems in place to review and escalate if needed.

The provider ensured that the least restrictive practice and rapid tranquilisation had not been used for nearly a year across all sites. Post rapid tranquilisation monitoring was comprehensive and included an option for soft measure visual assessment if the patient refused observations. Prescribing was in line with national guidance and no patients were receiving High Dose Antipsychotic Treatment (HDAT).

Pharmacists attended multidisciplinary team ward rounds (MDT) on all 3 sites, but pharmacists support was significantly more embedded at Astley Court and Elm ward where medication review was comprehensively done in conjunction with MDT colleagues. This ensured that all the necessary monitoring including physical health was taking place, reviewed regularly, and outcomes were easily available for all staff to access. Side effect monitoring was comprehensive at these two locations using recognised tools and pharmacists actively contributed to patient education and continuity of care. We saw examples where this comprehensive approach, in conjunction with medical staff, informed treatment decisions to minimise side effects from medicines such as evaluating whether a medicine that increases prolactin levels was the best option. De-prescribing (planned process of reducing or stopping medications that may no longer be of benefit) was actively encouraged and medicine reviews included outcomes from previous attempts to de-prescribe. Patients were actively included in these reviews. Easy read patient information material was available through Choice and Medication (a website providing information about mental health treatments to help make informed decisions).

At Astley court and Elm ward, the care plans were comprehensive and included rationale when medicines were used off-licence and evidence of best interest decisions. ‘When required’ (PRN) protocols were very comprehensive and included triggers, early warning signs and proactive strategies before any sedative medicines were considered for administration. However, care plans for medicines at Lexden hospital were not always as clear. The care plan for one person who was receiving a medicine off-label did not document in the care record whether the correct consent or best interest meeting had taken place. Another care plan and ‘when required’ (PRN) protocol was not up to date around the circumstances in which the administration of a sedative would be necessary.

Stopping over medication of people with a learning disability and autistic people (STOMP) audit had been completed in 2025 and found that psychiatrists had conducted clinical reviews consistent with the national standards. The subsequent learning ensured that adherence to these principles was always explicitly included in ongoing medication reviews and that any rationale for psychotropics was clearly documented. The service was developing an electronic version of this care document which could then be accessed by community teams post discharge.

Staff were involved in innovative work regarding anticholinergic burden (ACB) which was published in May 2025. This focuses on minimising the side effects from anticholinergic medicines such as dry mouth, gastrointestinal and eye problems, dizziness, sedation and dementia.

The provider ensured that all patients who were prescribed Sodium Valproate were compliant with the required national monitoring to prevent pregnancy and we saw, where following a best interest meeting, the decision to change therapy for one service user had been made.

Pharmacists provided education sessions and nursing staff told us they had received training in medicines, knew how to report medicines incidents and they received feedback and lessons were learned. One of the pharmacists actively contributes to the RADiANT network (Neurodevelopmental Research Stream and Research in Developmental Neuropsychiatry) which focuses on research, staff development and education for mental health and behavioural issues.

The Medicine Safety Oversight Group met regularly, reviewed audits and safety data including medicine incidents and ensured action plans were implemented.

Governance around monitoring of FP10 prescriptions needed strengthening at one location (Lexden hospital) as we found one FP10 prescription unaccounted for, the provider had already identified this from a recent audit in December 2025.