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 as good.

Staff delivered person-centred care, ensuring people and their carers received information about care and treatment in a way that was tailored to their individual needs. Staff supported individuals to engage in activities beyond the service, maintain independence and to maintain family and social relationships. The service was inclusive and responsive to the needs of people, including those with protected characteristics. Staff provided support with communication, access to advocacy services, and cultural and spiritual needs. Concerns and complaints were taken seriously, thoroughly investigated, and used as opportunities for learning and improvement. Staff also worked with people to plan for their future goals and aspirations. However, there was a delay in accessing psychology and occupational therapy services in some parts of the trust.

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 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 delivered care that was tailored to people’s individual needs, preferences and circumstances. Examples included offering appointments in a variety of settings, such as clinics, patients’ homes or via video consultation, to improve accessibility and accommodate mobility, health or personal needs.

Care plans generally reflected people’s cultural, religious and spiritual preferences, and staff made reasonable adjustments to support those with disabilities or communication needs. Therapeutic interventions and support groups were adapted to meet the differing needs of individuals, including those living with dementia, young onset dementia and other complex mental health conditions.

Staff used psychologically informed Network Meetings to promote person-centred care by placing patients and their identified support networks at the centre of discussions. Post-meeting letters and care plans demonstrated how discussions were summarised to support shared understanding and collaborative care planning.

Staff promoted shared decision-making and supported people to generally be involved in planning and reviewing their care and treatment. Patients were provided with information about treatment options, available support services and community resources to help them make informed choices.

We scored the service as 3. The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

The service demonstrated a good understanding of the diverse health and social care needs of people and the local communities it served, ensuring care was joined-up, flexible and promoted choice, continuity and positive outcomes.

The Trust’s Health Inequalities Plan, including its Patient and Carer Race Equality Framework (PCREF), supported efforts to reduce inequalities in access, experience and outcomes. Staff were knowledgeable about the needs of the population they served and routinely arranged interpreting services to ensure equitable access to care.

Older people had access to a range of specialist pathways for organic and functional mental health conditions, including medical, psychological and occupational therapy interventions. The memory assessment service provided assessment, diagnosis and ongoing support for people experiencing memory and cognitive difficulties, while occupational therapy interventions and the integrated care team promoted independence and supported people to remain living safely in their own homes where possible. The Trust had 5 trust wide pathways designed and approved and a trajectory in place for 6, the next phase was to implement them both in to digital systems, and clinically into workflows. The service was kept informed of trust wide pathway development.

The service used a caseload management model so that people who used the service had a care co-ordinator allocated to them and had continuity of care.

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 required, including safeguarding referrals to the Local Authority and statutory notifications to the Care Quality Commission (CQC).

The service provided information that was accurate, up to date and tailored to individual needs. It complied with the Accessible Information Standard, ensuring that people with disabilities or sensory impairments received information in formats they could understand and access.

The Trust’s website met recognised accessibility requirements, allowing users to adjust text size, colours and fonts. Information on treatments, local services, patients’ rights and how to complain was readily available, including through posters with QR codes displayed in waiting areas.

The service also facilitated forums for carers and service users to share feedback and receive information about services.

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 knew how to complain or raise concerns. When patients complained or raised concerns, they received feedback.

Staff protected patients who raised concerns or complaints from discrimination and harassment.

The service introduced QR codes on staff identification badges that linked directly to the Friends and Family Test (FFT) survey, making it easy for service users and carers to provide feedback in real time. Teams worked collaboratively and developed the idea of placing QR codes on staff badges, embedding feedback opportunities into everyday contact.

During the period 1 April 2025 to 31 March 2026, community older people’s services received 20 complaints and closed 25 complaints. Of those closed, 6 were upheld, 5 partially upheld, and 10 not upheld, with a small number not applicable to the Trust, withdrawn, or closed due to lack of consent. Complaints mainly related to patient care, access to treatment, trust administration and communication issues. Key themes included delays in accessing services, long waits for assessments and treatment and difficulties with referrals and continuity of care. Communication concerns were also raised, including poor updates to patients and families, inaccurate records, and inconsistent involvement of carers. Additional concerns related to the quality and safety of care, including clinical decision-making, risk management, and care coordination.

There were no Ombudsman investigations during the period.

PALS received 30 enquiries, mainly about communication, patient care, and administration. The service was able to analyse complaint and PALS feedback into themes and had an experience plan in place for 2025 and 2026 to make improvements. Themes reflected similar issues to complaints, particularly delays in access, poor communication between services and coordination difficulties, as well as concerns around safety, medication management, and safeguarding.

Despite this, 217 compliments were received, largely highlighting compassionate, person-centred care. Staff were frequently praised for being kind, respectful, and professional, with good clinical knowledge and clear communication. Overall, feedback reflected positive experiences of care and improved wellbeing for many service users and families.

Staff received feedback on the outcomes of complaint investigations and acted on the findings. This was evidenced through team meeting minutes and the sharing of learning summaries with staff, demonstrating that learning from complaints was shared and embedded within practice.

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 community mental health teams held a target to see 95% of people for an initial assessment within 28 days. Collectively, all teams achieved a compliance rate of 93% at March 2026. Data demonstrated an improvement with accessing initial assessments over time.

The service achieved its target, with 96% of service users commencing treatment within 18 weeks of referral. Waiting times were reviewed through regular case review in multidisciplinary team meetings and clinical supervision.

Crisis teams were responsive to patients who could access the service between 24 and 72 hours of contact. The trust met its compliance on this, achieving 100% in April 2026. The duty team at all sites were available to speak with or see patients that required immediate support and could immediately refer to the crisis team.

The Early Memory Diagnosis Assessment Support Service (EMDASS) achieved 63% compliance against the target of assessing 80% of people within 12 weeks of referral in March 2026. Performance was affected by an increase in referrals and reduced capacity due to staff vacancies. All vacant posts had now been filled, and the service monitored performance through weekly senior oversight meetings. Performance data showed continued improvement, with compliance levels moving back towards the target.

At the time of the inspection, waiting times for psychology assessments ranged from 0 to a maximum of 44 weeks. Waiting times for occupational therapy assessments and treatment ranged from 0 to a maximum of 65 days.

Staff planned for patients’ discharge, including good liaison with primary care services including GP’s and integrated care teams.

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 sought and responded to feedback from people who were more likely to experience health inequalities, adapting care and support to meet their individual needs.

Almost all staff had completed mandatory equality, diversity, inclusion and human rights training with a compliance rate of 99%.

The trust had completed a self-assessment against the NHS England Patient and Carer Race Equality Framework (PCREF) and had developed a co-produced action plan to address racial inequalities.

Equality impact assessments were also undertaken to ensure policies and procedures promoted equality and did not disadvantage people with protected characteristics.

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, including at the end of their life.

We saw evidence within care records that staff supported people and their families to plan for future changes, including the progression of illness, advance care planning, lasting power of attorney and future care arrangements.

The service also provided post-diagnostic support for people with dementia through specialist nursing input and links with voluntary sector organisations. Carers were supported to access information and community services to help them plan for the future.

Staff worked with relevant healthcare professionals and partner organisations to plan care for people with complex needs. Referrals were reviewed through multidisciplinary team meetings to agree the most appropriate care pathway and ensure people received support from the professional best placed to meet their needs.