Hertfordshire Partnership University NHS Foundation Trust

On this page

• 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

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

This meant people were safe and protected from avoidable harm.

The service managed safety incidents effectively and demonstrated a commitment to learning from these events to improve practice. Staff were skilled in assessing and managing risks to both people using the service and themselves. Individuals were appropriately supported throughout their care and treatment, including during transitions between services. Staff had a good understanding of safeguarding procedures and worked collaboratively with partner agencies to protect people from abuse. Service premises were safe, clean, well-equipped, appropriately furnished, well-maintained, and suitable for the needs of the people using them. The service employed sufficient numbers of appropriately qualified staff who received regular supervision and support. Effective systems were in place to prevent and control the risk of infection. Staff carried out comprehensive assessments of both the physical and mental health needs of people using the service. Individualised care plans were generally developed, regularly reviewed through multidisciplinary team discussions, and updated to reflect changing needs and circumstances. However, areas requiring improvement were identified during the inspection in relation to accessing health information from General Practitioners (GPs) and monitoring of Electrocardiogram (ECG’s) results for patients to ensure these had taken place.

This service scored 69 (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.

The service reported a total of 688 incidents in the last 12 months between 1st May 2025 and 30th April 2026. The majority of incidents related to service user ill health (age related), followed by slips, trips and falls and lastly, safeguarding incidents.

The trust had implemented Patient Safety Incident Review Framework (PSIRF) and had arrangements in place to review and respond to patient safety incidents in line with national requirements. A weekly Patient Safety Incident Panel reviewed incidents resulting in moderate or severe harm or death and used initial learning reviews to inform whether further investigation or learning responses were required.

The trust used a range of response methods, including Patient Safety Incident Investigations (PSIIs), After Action Reviews and Local Incident Reviews. Oversight was provided through the Safety Group, which monitored incident management, learning and improvement activity. The service held a Specialist Services Division meeting who reported monthly on patient safety performance and progress against key priorities, including violence and aggression, self-harm, restrictive practice, sexual safety and unexpected deaths.

The Trust had an overarching Safety Strategy 2025 – 2030 which is the Trusts commitment to deliver safe and effective care. The Strategy included the Trusts commitment to accountability, prevention, responsive, learning and safety.

Staff reported all incidents that they should, and knew what incidents to report and how to report them.

Staff received feedback from investigation of incidents, both internal and external to the service. Incidents and lessons learned were discussed at team meetings, local incident reviews, quality and risk management meetings, and the trust wide learning from deaths group. The trust also sent safety conversation bulletins to staff.

Staff understood and applied the duty of candour. They were open and transparent with patients and families, providing a full explanation when things went wrong. The trust monitored duty of candour compliance through incident reviews, and regular governance reporting. Staff were supported with guidance and training, and improvements were made to strengthen compliance, recording, and oversight.

The organisation used Systems Engineering Initiative for Patient Safety (SEIPS) swarms following patient safety incidents to support learning and improvement. These multidisciplinary reviews adopted a systems-based approach to understand how incidents occurred in practice, identify contributory factors, share learning across the organisation, and agree actions to reduce risk and prevent recurrence.

Key learning themes from incidents included strengthening risk assessment and care planning, improving communication and multi-agency working, enhancing safeguarding processes, increasing clinical oversight, improving documentation standards, supporting staff development and wellbeing, and strengthening responses to complex risk presentations.

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 service’s referral processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. Referrals came from the central triage team, the Single Point of Access (SPA). Patients self-referred to the service and referrals were also made by general practitioners (GPs), care homes, to and from crisis teams, inpatient wards and to and from integrated care teams where care centred around frailty and physical health concerns alongside social and mental health needs.

The service had clear referral acceptance criteria and completed triage assessments for all referrals. Where people did not meet the criteria for the service, staff signposted or referred them to mental health integrated care teams or talking therapies services to ensure their needs were met.

Community, crisis and memory teams worked well together to support each other with patients requiring support from various teams and during transitions of care. We observed meetings between community, crisis and memory teams as well as older adult and adult inpatient wards and community teams to ensure continuity of care and transitions were safe within and between services.

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 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.

The trust held quarterly safeguarding strategy meetings and adult community mental health services specific safeguarding meetings. Staff completed a quarterly safeguarding adults and children report where safeguarding oversight of mental health older people services were reported against. The meeting reviewed performance and ensured statutory responsibilities to protect adults and children from abuse and neglect were met.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. All staff were required to complete mandatory training in safeguarding. For level 1 safeguarding adults and children training, current compliance rates showed that 99% of staff had completed this with 97% of staff completing level 2 safeguarding children. For level 3 safeguarding adults training 98% of staff completed this and 94% of staff completed level 3 safeguarding children training.

The service monitored safeguarding cases overtime and had seen a reduction of cases to 20 open safeguarding concerns and enquiries between February and April 2026. The most common concern was neglect and acts of omission, followed by domestic abuse.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies such as social services, the police and other hospitals. Teams discussed cases in multidisciplinary team meetings and put appropriate safety measures in place.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. The 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.

The teams received clinical risk assessment and management training which 98% of staff had completed. Staff received simulation training on scenarios relating to dementia patients and carers and falls risks, risk formulation training, suicide prevention and suicide simulation training.

We reviewed 22 patient’s care records, including their risk assessments and risk management plans during the assessment. Staff carried out an initial risk assessment using a recognised tool and reviewed these regularly, including following any incident. Staff were aware of individual risks and took appropriate action to prevent or reduce harm.

Staff generally involved patients in care planning and risk assessment which we saw evidence of in care plans and in multidisciplinary team reviews. Patients had access to a copy of their care plan and letters following clinic appointments with clinicians.

Staff completed Rockwood frailty and falls risk assessments for patients to identify, monitor, and manage risks. This enabled staff to put appropriate measures in place to help reduce the likelihood of falls and support patients' overall safety and wellbeing.

Staff communicated effectively with patients to ensure they understood their care and treatment, adapting their approach for those with communication difficulties. A range of support methods were used, including easy-read materials, translated information, interpreters, and adjustments based on individual communication needs identified during assessments. In the memory service, staff completed pre-assessment forms to evaluate sensory needs, language barriers, communication abilities, memory changes, social confidence, and ability to follow conversations. This information was used to identify communication needs and tailor support before patients joined memory groups.

Services encouraged patients to provide feedback about the services they accessed. Every service we visited displayed QR codes and feedback boxes for patients to be able to provide feedback about the services. The trust also sought feedback from people using the services through their friends and family test and through the patient advice and liaison service (PALS).

Staff ensured that patients were able to access advocacy services when required.

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.

The trust completed regular risk assessments of each team’s environment including ligature risk assessments.

We reviewed the environments at Saffron Ground, Rosanne House, Oxford House and The Marlow’s health and wellbeing service which were all clean and well furnished. However, at Rosanne House, the carpet was stained in the reception area, and we observed a ripped seat in the clinic reception area.The Trust confirmed that the ripped seat had been replaced and the carpet cleaned.

Waiting rooms had sufficient chairs for people to sit and wait, with information boards displaying details of local resources, advocacy contact details, and information on how to give feedback including quick response (QR) codes. Each site had a television monitor with a slide show of useful information about the trust and a water cooler for patients to access drinking water if needed.

Staff booked rooms to see people for appointments and clinics. Most sites had access to larger rooms for groups and other sites that did not, used community settings for this purpose.

Staff all had access to alarms in meeting rooms and lone worker safety devices for when they went on home visits.

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

The clinic rooms we observed were clean and well-maintained, containing medication storage facilities and physical health monitoring equipment, such as blood pressure monitors. Records showed that this equipment was regularly serviced.

We scored the service as 2. The evidence showed some shortfalls. Vacancy and sickness rates did not consistently meet the trust's targets, and staff working in crisis teams described ongoing pressures in maintaining effective staffing levels. The service did not always make sure staff completed mandatory training, with compliance below the trust's target in some subjects.

Managers had calculated the number and skill mix of staff required to deliver the service safely.

At the time of the inspection, the 4 community teams visited had a combined vacancy rate of 6.3% posts against an establishment of 154.83 actual Full Time Equivalent (FTE) staff. Overall, this vacancy rate is below the Trust target of 8%. Full-time equivalent (FTE) is a measure of staffing that expresses the total hours worked by employees as the equivalent number of full-time staff. Vacancy rates across services for registered nursing staff was 8.34 FTE vacancies. Overall, the highest rates recorded in the crisis team was 15.8% (1.20 FTE) in April 2026 within the Northwest region at the Marlow’s Health and Wellbeing Service. This followed the crisis team at Oxford House (East Quadrant) who reported a vacancy rate of 10.6% (1.00 FTE).Vacancy rates in these teams exceeded the trust's target of less than 8%. Recruitment plans and mitigations were in place to ensure the provision of a safe service.

Staff working within the crisis teams described ongoing pressures in maintaining effective staffing levels. Staff reported that, to ensure adequate cover, they were frequently required to work additional hours, resulting in an accumulation of time owed that needed to be taken back at a later date. Staff told us they had raised concerns regarding staffing pressures with senior managers; however, some staff felt that sufficient action had not always been taken to address these concerns. At the time of the inspection, the trust was advertising and recruiting to vacant posts, particularly within teams experiencing the highest vacancy rates. Since the inspection, the Crisis Function Team has successfully recruited additional staff, and there are currently no substantive vacancies within the team. The Trust stated that safe staffing levels were maintained throughout this period, with any short-term operational pressures managed through leadership oversight and the use of time owed arrangements and bank shifts to ensure continuity of care.

Managers used bank staff to maintain safe staffing levels. For the crisis team in the North area of the trust at Saffron ground, there were 67 filled temporary shifts used across February and April 2026. All 67 shifts were filled by bank staff, and no agency shifts were recorded. The filled shifts were requested to cover sickness or vacancies. The trust did not use bank, or agency shifts at any other location during this time frame.

The average sickness absence rate in April 2026 was 5.4%, which was 1.4% above the trust’s target of 4%. In April 2026, the highest sickness rate by team, was 27.61% for the North Herts Crisis Function Team and 16% for the Community Mental Health Older People Southwest team. This exceeded the trusts target of 4%, however these sicknesses were in small teams and were being managed in alignment with the Trust absence policy, supportive plans were in place when staff returned to work. Following the inspection in June 2026, the sickness for the North Herts Crisis Function Team was reduced to 0% and the Community Mental Health Older People Southwest team was reduced to 14%, 2 staff remained on long term sick with 4 staff returning to work. The lowest was 0.75% in the East Hertfordshire crisis team at Rosanne House.

The staff turnover rate across the community teams was 5.8%, which was below the trust target of 12%.

The trust’s target compliance level was 92% for mandatory training. Overall, the service achieved an overall compliance of 95% for mandatory training, although not all topics met the trusts target of 92%. This included ligature awareness (90%), relating to people (90%), information governance and data security (89%). Additionally, this also included preventing radicalisation- basic prevent awareness (87%) and preventing radicalisation- prevent awareness (87%), level 2 basic life support (80%) and level 2 moving and handling training (81%). Following the inspection the Trust made improvements with ligature awareness (100%), information governance and data security (94%), preventing radicalisation- basic prevent awareness (94%), preventing radicalisation- prevent awareness (91%) and level 2 basic life support (91%). The Trust confirmed that any remaining staff would be booked onto future courses to ensure the compliance target was met.

The mandatory training programme was comprehensive and met the needs of patients and staff.

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 effectively assessed, managed, and controlled infection risks, taking prompt action to prevent the spread of infection and sharing concerns with relevant agencies when required.

Staff maintained equipment to a good standard, ensuring it was clean and appropriately labelled with in-date cleaning stickers.

Infection prevention and control principles, including hand hygiene, were consistently followed, supported by the trust’s infection prevention and control governance policy.

Staff training compliance for infection prevention and control was 95%.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

The services did not always have systems and processes in place for the safe and effective use of medicines in community mental health services.

Staff can access the Hertfordshire West Essex Shared Care Record (My Care Record) in Paris (the Trusts Electronic Patient Record). The Shared Care Record provides access to information from multiple health and care organisations, supporting continuity of care, informed decision-making and safer, more coordinated services. Although some staff reported they were not always able to access all information from primary care services related to patients' health. The Trust continues to remind staff about ‘My shared care record’. The Trust has issued a learning note to staff as a reminder of this.

Patients prescribed mental health medicines requiring an echocardiogram (ECG) were often referred to the GP for the ECG due to lack of facilities at the clinic. Whilst there was communication between the service and the GP, we could not be assured that patients requiring ECGs were receiving them as per trust policy. The Trust has taken immediate action to ensure the provision of ECG machines in community quadrants, supported by training and an online ECG interpretation service.

Staff told us there was limited clinical pharmacy support andthe service was reactive not proactive.Following our feedback to the leadership team, the Trust assured us that they are committed to strengthening pharmacy input into multidisciplinary team (MDT) working, particularly within community services.

Clinic rooms were clean, temperature controlled, with appropriate secure medicines storage facilities. There was access to emergency medicines. Medicines, including controlled stationery such as FP10 prescription pads (an FP10 prescription is the official NHS prescription form used in England by authorised prescribers to order medicines or appliances for supply to patients in primary care settings), were stored safely and securely. We saw evidence that staff had safe processes in place for transportation of medicines to people’s homes. Staff told us how they report medicines incidents and how learning from these incidents were shared. However, we saw that actions taken following reported side effects, or investigations undertaken were not always clearly documented

The Trust has a frailty nurse consultant who worked across both inpatient services and the community. The consultant nurse worked closely with physical health nurses, and pharmacy staff to review medicines risks, training, and policy.

Bespoke and online training on medicines management were available. In some areas, staff told us of bitesize training on side effect training. However, staff told us that this was not available at all sites.Staff undertook online mandatory medicines optimisation training for prescribers and registered nurses which was 100% and 92% compliance respectively.

Staff carried out structured medicines reviews, for people taking multiple prescribed medicines, to identify those that may cause side effects in older adults such as increased risk of falls or impacts on memory and thinking, while promoting deprescribing (the planned and supervised process of reducing or stopping medicines that may no longer be beneficial, are no longer needed, or where the potential harms outweigh the benefits).

The physical health clinic, clozapine and depot clinics, were well developed and worked proactively to engage with patients, completing health checks for people with severe mental illness (SMI). Staff carried out physical health checks and baseline monitoring for antipsychotics and mood stabilisers in line with NICE guidance. The clinics used nationally recognised tools for monitoring and management of medicines related side effects. Staff also used side-effect rating scales, including the Glasgow Antipsychotic Side-effect Scale (GASS), to support medicines optimisation. Where people were prescribed long-acting depot injections which required extra monitoring after administration, the service had appropriate guidance in place to support staff with monitoring and recording people’s health after administration. Staff were able to describe the process they followed for patients who did not wish to engage with depot clinics. Medicines information leaflets were provided in multiple languages and easy read format.