Hertfordshire Partnership University NHS Foundation Trust

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.
At our last assessment we rated this key question good. At this assessment the rating has remained good.
Staff managed beds well. A bed was available when a patient needed one. Patients were not moved between units, except for their benefit. The design, layout, and furnishings of the unit supported patients’ treatment, privacy and dignity. Staff supported patients with activities outside the service, such as work, education and family relationships. The service met the needs of all patients – including those with a protected characteristic. Staff helped patients with communication, advocacy and cultural and spiritual support. The service treated concerns and complaints seriously, investigated them and learned lessons from the result.
This meant people’s needs were met through good organisation and delivery.

This service scored 79 (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 3. The evidence showed a good standard. The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.
Staff regularly met with patients to understand their views on care and treatment. These discussions took place in one-to-one meetings with nurses and in multidisciplinary team meetings. Staff monitored patients’ presentation and discussed any changes at handover meetings. Patients were involved in decisions about their care and treatment.
The service provided therapeutic and recreational activities to meet the needs and personal interests of patients. A timetable of appropriate therapeutic activities was shared with patients. Patients said they participated in food preparation sessions, quizzes, played games and watched films.
Patients had access to psychology input either in groups or 1-1 sessions. Psychology interventions included cognitive behavioural therapy (CBT) and supported patients with emotional management and coping strategies. Psychology staff provided relapse prevention work which supported patients working towards discharge.
Occupational therapy staff provided an example of how they supported patients who did not wish to engage in therapeutic activities. Staff utilised a re-motivation approach with timeframes agreed with the patient on how often they would offer purposeful interaction. Staff offered different things tailored to the individuals, made themselves available and were approachable. Staff described an example where this approach had proved successful as a patient began to engage with staff when they were ready.
 

We scored the service as 4. The evidence showed an exceptional standard. The service had an exceptional understanding of the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.
Staff supported patients to maintain continuity of care in the community and supported patients to be discharged when they were clinically ready. Leaders set up a service in the community, known as the Enhanced Rehabilitation Outreach Service (EROS). This was a way of removing some of the barriers to discharge. It meant that patients could be discharged to the community and remain under the care of a trust consultant. It meant that some patients were discharged from hospital sooner than they would have been without the outreach team. Patients were usually under the supervision of the outreach team for 16-20 weeks before being discharged to the local community mental health team. A longer-term provision was also available for more complex cases. This process supported patients’ discharge and integration into the community. It also reduced readmissions from the community.
Staff supported patients to access the community and take part in activities outside of the service. Patients could access work opportunities and community based leisure activities. Staff had supported patients to access volunteering opportunities in the community and had a recent example where that had led to paid employment. These opportunities supported patients to build confidence, skills and community integration. Patients participated in a wide range of other community activities, including shopping trips, family visits and day trips. Engagement in structured activity was reviewed through assessment and MDT discussions. It was then incorporated into goal setting and discharge planning arrangements to support successful discharge into the community.
Staff supported patients to maintain contact with their families and carers. All patients we spoke to told us they were supported to maintain contact with the people who were important to them. Staff told us they were able to support visits from children in a suitable environment.
Staff supported patients to maintain contact with people in their local area. Staff ensured family members and care co-ordinators were invited to multidisciplinary team meetings. The service facilitated attendance by video link if people were unable to attend the hospital in person.
 

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.
Staff made notifications to external bodies as needed. The service submitted notifications to the Care Quality Commission in accordance with the requirements of their registration. The service also submitted safeguarding referrals to the local authority.
Leaders had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care. Leaders attended monthly quality and risk management meetings where performance information was shared and discussed.
Staff made sure patients could access information on treatment and local services. Information leaflets were available, which included information about the recovery college, sexual safety, wellbeing and addiction. Staff displayed information about safeguarding, the Mental Health Act and the independent mental health advocacy service.
Staff ensured commissioners, relatives and carers were regularly updated about patients’ progress. They were invited to attend ward rounds and Care Programme Approach (CPA) meetings. Carers told us they knew how to contact staff if they wanted an update on patients’ progress.
 

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.
Patients and staff participated in regular community meetings on the units. The patients and staff we spoke to told us that community meetings were useful. The meetings allowed an open culture on the unit where both patients and staff could raise issues, discuss actions taken and suggest solutions. We reviewed community meeting minutes and found there were discussions on topics such as environment, safety and food. Where an action log was completed, we saw progress on the actions had been reviewed.
Patients, relatives and carers knew how to complain or raise concerns. Patients said if they had any complaints, they would speak with nursing staff, their doctor or the team leader. One carer told us they advocated on behalf of their relative, staff listened to their views and the matter was resolved. Leaders shared learning from complaints with all staff.
The service clearly displayed information about how to raise a concern in patient areas. Staff understood the policy on complaints and knew how to handle them. Each complaint was assigned to an individual investigator.
During the period August 2025 to February 2026 the service received 2 complaints. Both complaints were resolved through early resolution which the patients were satisfied with. Patients received feedback after the investigation into their complaint. All complaints were reviewed at trust level, with outcomes and response times tracked, learning identified and themes monitored over time.
The service received 10 compliments from August 2025 to February 2026. Themes from compliments included positive impact on confidence, engagement and recovery, supportive and compassionate staff relationships, and positive outcomes.
 

We scored the service as 3. The evidence showed a good standard. The service made sure that people could access the care, support and treatment they needed when they needed it.
The service had sufficient medical cover day and night, a doctor could attend the unit quickly in an emergency and the units were within a reasonable travelling distance to the local acute hospitals.
Staff ensured patients had access to post-discharge care, including section 117 aftercare, community mental health and crisis services. Staff planned for patients’ discharge, which included good liaison with care co-ordinators.
Most of the service was accessible to patients, including those with restricted mobility and wheelchair users. Hampden House and Gainsford House were situated across one level. The Beacon and the step-down house had 2 floors with no lifts. Patients with reduced mobility or wheelchair users could still be accepted at the Beacon because there were 2 bedrooms available on the ground floor. However, the step-down house was not an accessible environment as all bedrooms were upstairs.
Delayed discharges were not always due to clinical reasons. Information provided by the trust showed there were 2 delayed discharges at the time of the inspection. Appropriate action had been taken to address the reasons for delay and to ensure the patients’ needs would be appropriately met.
 

We scored the service as 3. The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.
The service admitted patients from diverse religious and cultural backgrounds. Staff asked patients about their religious and cultural needs when they were admitted to the unit. If required, patients were supported to buy and prepare culturally appropriate food. People had access to chaplains, who worked alongside other health professionals to provide religious and spiritual care for people.
Staff made adjustments to accommodate patients with diverse needs. Information was also made available in various formats to ensure accessibility. Information could be made available in different languages and staff had access to resources such as communication cards.
Staff were trained in equality, diversity and human rights. Staff compliance with this training was 100%. Staff also completed the Oliver McGowan mandatory training on learning disability and autism. Compliance with this training was 100%.
 

We scored the service as 3. The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future.
Staff ensured all relevant healthcare professionals and other relevant bodies were involved in planning the care and treatment of people with complex needs. The multi-disciplinary teams within the service were made up of consultant psychiatrists, specialty doctors, nurses, healthcare assistants, psychologists, occupational therapists and other support staff.
The multidisciplinary team planned for each patient’s discharge. Staff ensured that appropriate arrangements were in place to sustain the patient’s mental health when they left the service. This included liaising with other professionals involved in the patient’s care to ensure they had appropriate accommodation to be discharged to and that a package of care was provided by the local mental health services. Alternatively, some suitable patients were supported by the trust’s Enhanced Rehabilitation Outreach Service (EROS).