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

This means we looked for evidence that people were protected from abuse and avoidable harm.
At our last assessment we rated this key question good. At this assessment the rating has remained good.
All units were safe, well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.
This meant 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.

We scored the service as 3. 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.
Staff reported incidents clearly and in line with the trust policy. Staff knew what incidents to report and how to report them. Staff recorded incidents on an electronic incident reporting system. All incidents were reviewed and addressed appropriately according to the level of severity. Between September 2025 and February 2026 133 incidents were reported across the service. During this timeframe, there were 23 incidents of violence and aggression, 15 medication incidents and 8 incidents of self-harm.
Managers investigated serious incidents thoroughly using the Patient Safety Incident Response Framework (PSIRF). Staff reviewed closed-circuit television (CCTV) footage as part of the investigation process to identify areas of improvement and good practice. The multidisciplinary team (MDT) reviewed incidents and any emerging themes or trends. Information from these discussions were escalated through divisional quality and risk meetings where required. Governance processes showed leaders had oversight of incidents and took action to manage risks.
Staff met to discuss learning from incidents which was shared in a variety of ways. Staff told us they received regular communications about learning from incidents via email. If an incident took place on their unit, it would always be discussed in handover, and staff told us they received debriefs and reflective practice sessions following incidents. Staff received feedback from internal and external incident investigations. For example, staff told us about a trust-wide change in practice following a national safety alert regarding the risks of plastic bags.
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 provided information on the trust’s standards and expectations in relation to the duty of candour.
 

We scored the service as 3. 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.
The trust’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 within the county of Hertfordshire. This could be from other types of wards, such as acute, or from a community setting. Eligibility requirements were that patients were over 18 years of age and required rehabilitation in an inpatient setting. The Beacon was set across 2 floors, so mobility was a consideration for eligibility there.
Referrals were managed centrally in the trust by a panel which consisted of rehabilitation consultants, managers and a senior clinician. Clinical teams undertook the assessments, and the panel made the decision whether to accept the referral based on the information and recommendations in the assessment report. The trust aimed to complete assessments within 5 working days of referral. If a referral was not accepted to the service, the panel signposted referrers to alternative providers.
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. Other agencies involved with patients’ care were invited to attend ward rounds and could attend virtually if that was preferred.
Staff ensured that patients’ discharges from the service were managed safely. Discharge planning began at a patient’s first ward round. Patients were discharged to supported or independent accommodation in the local community. Staff liaised with the appropriate services to ensure robust discharge plans were in place. Patients had periods of trial leave before they were discharged.
 

We scored the service as 3. 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.
Staff received training on how to recognise and report abuse, appropriate for their role. Staff compliance with safeguarding training for adults and children at levels 1, 2 and 3 were 100% across the service. Safeguarding leads were identified locally and there was a trust safeguarding team.
Staff gave examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff gave us examples where they had raised safeguarding concerns relating to potential financial abuse. Staff reported 7 safeguarding concerns across the rehabilitation service between September 2025 and February 2026. Staff followed the trust safeguarding policy which provided clear guidance on how to respond to safeguarding concerns.
Staff knew how to recognise adults and children at risk of or suffering harm and worked with other agencies to protect them. Staff submitted safeguarding referrals to the local authority appropriately. Safeguarding noticeboards in the unit offices also provided contact details for the local safeguarding authority.
All the patients and carers we spoke with told us they or their loved ones felt safe on the units.
 

We scored the service as 3. The evidence showed a good standard. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint only after attempts at de-escalation had failed. The unit staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.
Staff completed risk assessments for each patient on admission using a recognised tool, and reviewed them regularly, including after any incidents. We reviewed 11 patient records during the inspection. All records included risk assessments and risk formulation.
There was evidence of patient and carer involvement in all records we reviewed. Patients and some carers were offered a copy of their care plan. Patients were given the opportunity to participate in their ward round reviews. All care plans we reviewed were personalised to the individual.
Staff identified and responded to any changes in risks to, or posed by, patients. Staff used de-escalation techniques to initially respond to escalations in patients’ risk and followed best practice in managing risks. The multidisciplinary team (MDT) discussed incidents and changes to patients’ risks at handover meetings and ward rounds. Staff responded to risks appropriately by reviewing medication, observation levels and access to leave.
Staff followed provider policies and procedures when they needed to search patients or their bedrooms to keep them safe from harm. Staff searched patients when they returned from leave based on individual assessment of risks.
Staff participated in meetings to review blanket restrictions and try to reduce them. The trust had a Blanket Restrictions Policy which guided staff on why these measures would only be used where necessary to respond to an identified risk. The trust had processes in place to review and manage blanket restrictions and restrictive interventions at corporate and divisional levels which led to improvements in practice, such as trauma informed approaches to care.
Staff were aware of restrictive practices that took place in the service. For example, there was a temporary restriction in place at Gainsford House and Hampden House. The windows in patient bedrooms had been reviewed and were deemed to pose a ligature risk. To mitigate that risk, all patients were placed on 30-minute observations. At the time of the inspection, this restriction was close to being removed and the work was completed by the end of February 2026.
Levels of restrictive interventions were consistently low. Between September 2025 and February 2026, the service had no recorded incidents of prone restraint. Prone restraint is where the patient is restrained facing the ground. During the same period there had been no instances of rapid tranquilisation across the service, and only 1 incident where physical intervention was required.
However, risk management plans were not always comprehensive. They indicated actions taken in response to an incident, rather than a robust plan for ongoing management of the risk. In some cases, we did not see associated risk management plans for identified risks. For example, one patient had an identified risk of substance misuse. The risk was considered in the patient’s care plan; however, it was not indicated in the risk assessment. Another patient was at risk of financial exploitation, but there was no management plan to guide staff on how to manage the risk. Following the inspection, the trust informed us that all care plans and risk assessments were reviewed and updated to ensure that risk management plans were in place for all identified risks.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.
During the inspection, we visited all 3 units in the rehabilitation service. Staff were not able to observe patients in all areas of the units and outside spaces. However, the service had fitted convex mirrors and closed-circuit television (CCTV) to monitor communal areas and used enhanced observations to support patients with additional risks.
Staff completed regular risk assessments of the care environment and removed or reduced any risks they identified. For example, staff completed weekly ligature audits across the service and escalated any concerns identified. Staff conducted daily environmental checks of all the units. Staff knew about any potential ligature anchor points and mitigated the risks to keep patients safe.
All the units had a ‘Patient Safety at a Glance’ interactive whiteboard in the nursing office, which displayed information about all patients. This included observation levels, section 17 leave, allocated keyworkers and risks.
The service complied with NHS guidance on delivering same-sex accommodation. All of the units in the service were mixed sex units, but there were separate bedroom corridors for males and females with separate bathrooms. There were also female only lounges available in all units.
Staff had easy access to alarms and patients had easy access to nurse call systems. These were present in patients’ bedrooms, accessible toilets and communal areas of the units.
Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.
Each patient had their own bedroom. Staff told us that patients were able to personalise their bedrooms. In the bedrooms we saw service users had chosen to display only a few personal photographs. All patients’ rooms had whiteboards, Some had the names of key staff written on their boards, others had shopping items listed. Bedrooms were not all ensuite, however there were sufficient male and female bathrooms, so patients did not have to wait if they wanted to access one.
Some of the décor at The Beacon and Hampden House appeared tired. Leaders had plans to improve this; maintenance requests for repainting had been submitted and leaders told us about plans to introduce more décor with input from patients and an art therapist at The Beacon.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.
The service had enough staff to keep people safe. At the time of inspection, the overall vacancy rate for all 3 rehabilitation units was 8%. Vacancies were mostly within additional clinical services as a result of reduced staff hours. There was a vacant social worker post at the Beacon and a vacant occupational therapist post. The service was in the process of recruiting to these vacancies. Turnover of staff for the last 6 months was 2.1% against a target rate of 10% across the trust. Staff sickness for the last 6 months was 4.6% against a target rate of 4%.
Managers could adjust staffing levels daily to take account of case mix. For example, if patients required constant observations, the corresponding number of staff required were added to the required numbers.
When necessary, managers deployed bank nursing staff to maintain safe staffing levels. The service had not used any agency staff in the 3 months prior to the inspection. Bank staff were regular and knew the service well. New bank staff received an induction and were oriented to each new unit.
Managers had oversight of shifts being filled. In the event that it was not possible to fill a shift, team leaders provided cover to ensure there was no disruption to services. All the units were adequately staffed.
There were enough staff to carry out physical interventions, for example, observations and restraint safely. There was adequate medical cover day and night and a doctor could attend the unit quickly in an emergency.
Staff were given a comprehensive induction to the service to ensure they were prepared for the role.
Staff had received and were up to date with appropriate mandatory training. Overall compliance with mandatory training was 98% The training was appropriate for the patient group using the service.
Staff received regular supervision on a monthly basis. Managers monitored compliance with supervision. At the time of the inspection, supervision rates were 100% across the service.
Leaders supported staff to develop through yearly, constructive appraisals of their work. 100% of staff across the service were up to date with their appraisal at the time of the inspection.
 

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.
The service conducted a number of infection prevention and control (IPC) audits as part of the trust’s audit programme. Staff carried out monthly audits in IPC compliance, which included hand hygiene observations and decontamination of equipment. Matrons undertook a monthly IPC walkabout. Some staff within the service took on the role of infection control lead nurses and assisted in completing local audits.
Housekeeping staff cleaned the units on a daily basis. We observed that most unit areas were clean, furniture across the service was mostly in good condition, however some of the décor appeared tired in places.
Staff followed IPC policy, including handwashing. Staff could access personal protective equipment (PPE) as required. Staff compliance rate for level 2 infection prevention and control training was 100%.
During the inspection we raised some concerns relating to the cleanliness of the environment. The trust provided immediate assurance. For example, there were marks on one of the walls in a vacant patient bedroom. This was immediately cleaned, and staff had already identified the issue and submitted a maintenance request for repainting.
 

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.
During an inspection in 2015, the provider had the following breach: ‘We found that patients were not protected against the risks associated with the unsafe use and management of medicines. This related to the rehabilitation units not having appropriate arrangements in place for obtaining, recording, and dispensing medicines.’ During this inspection, this had improved. Systems were in place to safely prescribe, administer store, and order medicines. Medicines were prescribed using an electronic prescribing and administration system (ePMA).
There was a comprehensive process in place to support people to take their own medicines. This followed a risk assessment by a multidisciplinary team to ensure patients self-medicated safely. This approach promoted better understanding of their medicines, improved concordance and supported greater independence in preparation for discharge.

We were shown a case study related to self-administration of medication(SAM). A service user had a documented history of non-concordance with antipsychotic medication. This service user was supported to progress through the 4 stages of self-administration. The staged programme empowered patients and promoted their independence.
Mental health act (MHA) authorisation forms were available to staff when prescribing and administering medicines to ensure that they were prescribed with legal authorisation. However, we saw one instance where a medicine had been prescribed which was not authorised on the MHA form. Staff took immediate action to rectify this.
Clinical pharmacist support was embedded across the service. Pharmacists attended the units regularly, carried out medicines reconciliation and provided medicines advice and support. We reviewed clinical records and saw that people had regular medicines reviews, with adjustments made to treatments based on clinical parameters and where appropriate, their preferences. When required (PRN) medicine protocols included clear indications and maximum doses which staff used to support people. When PRN was administered, staff documented the rationale and if they had been effective. People’s behaviour was not controlled by inappropriate use of medicines.
Staff had received medicines training. Whilst staff understood the medicines needs of the people they were supporting, this information was not always documented in care plans.
A previous quality improvement project to strengthen physical health monitoring had been successfully embedded into practice. Staff on the long stay rehabilitation units completed daily and monthly physical health observations and escalated concerns promptly to clinicians. Audit results showed improvements in the completion of these checks. Physical health assessments were undertaken in line with National Institute of Care and Excellence (NICE) guidance to ensure safe ongoing treatment.
In addition, there was effective multidisciplinary collaborative working with the local GP practice who reviewed people regularly and supported the management of physical health conditions.
We reviewed the records for 2 people who were prescribed high dose antipsychotic treatment (HDAT), which requires enhanced monitoring. We identified that staff had not completed the HDAT forms in line with trust policy. Following our feedback, the trust was very responsive and took immediate action to address this.
There were clear processes for managing and reporting medicines related incidents. Staff were able describe the steps they would take if an incident occurred. Medicine incidents were reviewed regularly, and learning was shared via team meetings.
There was good oversight of medicines management with regular audits conducted and discussed in medicines safety oversight groups. When issues were identified, action plans were implemented.