Hertfordshire Partnership University NHS Foundation Trust

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment, and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment, the rating has remained good.

Staff assessed the physical and mental health of all patients on admission. They developed individual care plans which were generally reviewed regularly through multidisciplinary discussion and updated as needed. Staff provided a range of treatment and care for patients based on national guidance and best practice. The ward team included or had access to the full range of specialists required to meet the needs of patients on the ward. Staff from different disciplines worked together as a team to benefit patients. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well.

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’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Staff completed a comprehensive assessment at first contact, covering mental health, physical health, social care needs, and risk. This enabled information to be shared between teams and care coordinators, reducing the need for people to repeat their needs when transferred or signposted to other services.

We reviewed 22 care records across all sites and found that staff generally involved patients in care planning. However, at Oxford House, care plans were not always up to date. Of 6 care plans reviewed, 3 lacked evidence of being current, personalised, holistic, or recovery focused. We also found no evidence that copies of care plans had been provided to patients, despite asking staff to show us. This was raised with the Trust at the time who took immediate action to address these concerns. The wellbeing care plans have been completed in collaboration with the service users and reflect the service user's recovery goals. The Trust have since taken further steps to improve the quality and standards of care plans. There have been three Trust-wide workshops focusing on standards of clinical documentation including care plans, and a care plan clinic.

Health check compliance was generally high across community teams. Reported figures were based on small numbers of patients, as only those with a serious mental illness diagnosis who are on CPA, were included in a dashboard to monitor compliance. In April 2026, two teams achieved 100% compliance. Where health checks remained outstanding, actions were underway to complete assessments, with 1 overdue review escalated for urgent follow-up. Additional monitoring was undertaken for service users prescribed high-risk psychotropic medication who were not captured within the dashboard. Overall, 93% of service users had physical health assessments completed or in progress, with plans in place to ensure all outstanding assessments were booked by June 2026.

We scored the service as 4. The evidence showed an exceptional standard. The service always planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation. They worked to develop evidence-based good practice and standards. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well

Staff delivered a range of evidence-based interventions appropriate to the needs of the patient group and in line with National Institute for Health and Care Excellence (NICE) guidance.

Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice, and the guiding principles.

The teams included, or had access to, the full range of specialists required to meet the needs of patients using the service, including doctors, nurses, occupational therapists, clinical psychologists, social workers, pharmacists, speech and language therapists, and dietitians.

The service assessed and treated both organic and functional mental health conditions. Prescribing followed trust policies and national guidance, with treatment decisions based on patients' clinical presentation, diagnosis, physical health needs, and risks. Patients and families received information about medicines and side effects and were encouraged to raise concerns. Treatment was reviewed regularly, and staff administered depot medication and monitored clozapine treatment in line with national guidance.

The multidisciplinary team offered a range of therapeutic interventions. Psychologists delivered psychological therapies, including cognitive behavioural therapy, dialectical behaviour therapy, and trauma-informed interventions. At some locations, eye Movement desensitisation reprocessing (EMDR) therapy and systemic therapy were offered. Psychological group interventions were also offered to patients living with memory difficulties, providing support, education, and strategies to help individuals manage the impact of cognitive impairment on their daily lives.

Occupational therapists completed functional assessments and supported patients to maximise their independence through assessments and interventions. They also offered memory groups, an anxiety management group, a walking group, and a recovery through activity group which supported mental health recovery through participation in meaningful activity.

Community teams attended a monthly frailty surgery where staff from MDT participated in complex case discussions, shared learning, and coordinated decision-making, with participation from community, mental health, pharmacy, and allied health professionals. Education was closely linked to clinical practice through teaching sessions, simulation training, and case-based learning, helping staff develop clinical reasoning, recognise deterioration, and manage risk effectively.

The service worked closely with the Integrated Care Team (ICT) to support individuals with complex health, mental health, frailty, and social care needs. The ICT provides multidisciplinary assessment, care coordination, crisis prevention, discharge support, and short-term interventions aimed at promoting independence and preventing unnecessary hospital admissions. Staff described positive collaborative working with the team and reported that ICT involvement helped ensure that individuals received coordinated support from health, social care, and community services where required.

Staff were experienced and qualified and had the right skills and knowledge to meet the needs of the patient group. Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. Staff had access to a range of specialist training to support their practice. This included training in Making Every Contact Count, risk assessment, formulation and risk management, falls simulation training, the use of medication side-effect rating scales, high risk medication, and the safe management and monitoring of clozapine treatment.

The service used audits and quality improvement initiatives to support the safe management of medicines. In July 2025, a Fundamentals of Care Dashboard for patients receiving depot medication and clozapine treatment was introduced, providing staff with oversight of medication administration, physical health monitoring, and clinical reviews. The dashboard had previously received national recognition through a Health Service Journal Patient Safety Award.

A re-audit of antipsychotic side-effect monitoring using the Glasgow Antipsychotic Side Effect Scale (GASS) demonstrated improved compliance with monitoring and increased patient engagement. The trust also participated in the national Prescribing Observatory for Mental Health (POMH-UK) audit programme, with findings used to inform service improvements and medicines governance.

Managers provided new staff with a full induction, and all staff received regular team meetings, supervision, and an annual appraisal. At the time of the inspection, 88% of staff were up to date with all required supervision, while 89% of registered nursing staff were up to date with clinical supervision. The service ensured that staff received an annual appraisal, achieving a compliance rate of 99.3%. In addition to full induction, the Clinical Matron for the service offers a bespoke meet and greet with new students with the purpose of supporting student nurses with orientation to services, staff roles, learning opportunities, top tips for a successful placement, expectations, nursing roles within mental health older people services and career development within the speciality. Previously Mental Health Community Mental Health North team were shortlisted as finalists for the Student Community Placement of the Year category at the Student Nursing Times awards.

We scored the service as 3. The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff held effective multidisciplinary meetings each week where within each patient discussion, staff provided details of recent visits, highlighting any changes to the patient’s circumstances and presentation. This included details of the views of the patient, their family and other professionals that were working with the patient. The team agreed a plan for the patients that typically involved bringing forward planned visits, reviewing medication, arranging capacity assessments, or liaising with other professionals.

Staff shared information about patients at effective handover meetings within the team. Community teams, crisis teams, memory service staff, and integrated care teams regularly held meetings to discuss patients they were caring for, to see how they could best support them, transition care, or work across teams.

The teams had effective working relationships with teams outside the organisation for example, local authority social services, primary care and GPs.

The Trust and the local community Trust have worked together using the tools; Stopping Over Medication of People with a learning disability (STOMP), Screening Tool of Older Persons Prescriptions in Frail adults (STOPPFrail), and the Screening Tool of Older Persons' potentially inappropriate Prescriptions and Screening Tool to Alert to Right Treatment (STOPP/START) to proactively reduce avoidable medicine related harm. These proactive reviews led to a total of 75 medication changes being made, of which 57% resulted in medications being stopped.

We scored the service as 3. The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

A structured frailty model was embedded across community services, supporting the early identification and management of frailty through a community frailty pathway, monthly multidisciplinary frailty surgery, workforce training, simulation-based learning, and governance oversight. Staff received training in frailty assessment, including the Rockwood Clinical Frailty Scale, falls risk assessment, physical health monitoring, polypharmacy, deprescribing, and advance care planning.

Staff supported patients to live healthier lives – for example, occupational therapy staff facilitated memory groups, anxiety management groups, walking groups, and a recovery through activity group which supported mental health recovery through participation in meaningful activity.

The service had an Occupational Therapy assistant-led walking group to improve older adults’ resilience, mobility, and health. The service believed this was a sustainable, preventative approach that addressed inequalities, was cost effective and promoted community-based care. The walking group was tailored to older adults’ abilities and followed National Institute for Health and Care Excellence and Public Health England guidance. Sessions encouraged peer interaction, storytelling, and a connection to nature. The walking group diary captured and reflected ideas, and growing bonds between walkers. This low-cost, person-centred intervention addressed key risks linked to mental decline, falls, and social disconnection all of which contributed to unplanned hospital admissions and long-term care needs. The service used this intervention based on evidence from research studies demonstrating that walking groups reduced depression, improved cardiovascular health, and promoted wellbeing in older adults.

The service had the support of Senior Physical Health Support Workers (PHSW), working across the 4 Mental Health Older People and Crisis Function teams. The PHSW main focus was the delivery of annual physical health checks for people with Serious Mental Illness. The majority of physical health checks were completed in service users own homes, this was supportive of improving access to annual physical health checks. The PHSW reduced potential barriers of access to physical healthcare and the known health inequalities for people with a Serious Mental Illness, whilst also recognising additional needs in older adults and frailty.

Staff generally assessed, managed, and monitored physical health needs of patients.

We scored the service as 3. The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Staff used recognised rating scales to assess and record severity and outcomes. For example, Health of the Nation Outcome Scales and the Rockwood frailty scale to assess patient overall level of fitness, function and vulnerability and patient reported outcome measure and quality of life (PROMs) where patients’ self-reported their satisfaction across 11 key life domains. The services also used various cognitive outcome tools to monitor cognitive functioning, deterioration, and progression.

Staff used technology to support patients effectively. The trust launched an innovative pilot in South West Hertfordshire to support people awaiting dementia assessments. The pilot used a smartphone app to remotely monitor cognition, quality of life, daily functioning, medication use, and physical health indicators, with the aim of improving assessment and care planning.

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

The service informed people of their rights relating to consent and respected these when delivering person-centered care and treatment. We reviewed 22 care records and found that staff assessed patients’ mental capacity where appropriate, recorded informed consent to treatment, and involved patients in decisions about their care and treatment options.

The trust had a Mental Capacity Act policy in place, and 97% of staff were up to date with Mental Capacity Act and Deprivation of Liberty Safeguards training.

The service also provided access to an independent advocacy service. Information about the service was displayed in reception and waiting areas, and staff supported patients to access advocacy, including helping to arrange appointments where required.

For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions.

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture, and history.

Staff contributed to deprivation of liberty safeguards applications when required and monitored the progress of applications to supervisory bodies.

Staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it.

A small number of patients were subject to community treatment orders (CTO). The service undertook audits to monitor compliance with requirements under Section 132 of the Mental Health Act, ensuring that people subject to Community Treatment Orders (CTOs) had their rights explained to them. Compliance with the requirement to explain rights to people subject to Community Treatment Orders within the required timescales was 100%.