Sussex Partnership 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

Are services safe? This means we looked for evidence that patients were protected from abuse and avoidable harm.

At our last inspection we rated this key question as requires improvement. At this inspection, the rating remained unchanged. We rated it as requires improvement which meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that patients could be harmed.

The service did not manage medicines safely, the service did not always have enough medical cover, the service did not comply with mixed sex accommodation safety guidance, the 136 suites were not always available for patients who needed urgent care and treatment, staff did not ensure that the health and wellbeing of patients using the services were always assessed and safely managed, and staff did not always ensure that the environment was cleaned to a high standard.

The service was in breach of Regulation 12: Safe care and Treatment and Regulation 13: Safeguarding service users from abuse and improper treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 44 (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 knew what incidents to report and how to report them. Staff reported all incidents that they should report. The service reviewed incidents in line with NHS England’s The Patient Safety Incident Response Framework (PSIRF). PSIRF is a new system used by the NHS to respond to and learn from patient safety incidents. It replaced the Serious Incident Framework and focuses on a culture of learning, compassionate engagement with those affected, and proportionate responses to improve patient care.

The service reported 11 patient safety incidents investigations (PSII) in last 12 months. PSII is a process whereby healthcare providers learn from and improve patient safety incidents. The investigations were thorough, robust, and lessons were identified. Staff were debriefed and received support after a patient safety incident.

The crisis resolution and home treatment teams reported 109 incidents in the last 3 months. These incidents ranged in severity and included death of people using the service, self-harm, bed delays, violence and aggression and medication related incidents the last 3 months. The health-based places of safety reported 88 incidents in the last 3 months. These incidents ranged in severity and included medication related incidents, physical ill health, privacy and dignity, self harm, violence and aggression and s136 closure.

The trust reported that 77 instances between June 2024 and June 2025 when the s136 suites were decommissioned to support patient’s care and treatment.

Staff who were lone working had a safety device which alerted the teams in an emergency.

Staff discussed Incidents, any investigations and learning from the reviews or investigations both internally and external to the service including at handover meetings, staff team meetings, and multidisciplinary team meetings. The trust shared learning from incidents with staff via number of channels including via emails and through the trust’s newsletters.

Staff understood the duty of candour. They said it was about being open and transparent and gave patients and families a full explanation when things went wrong.

The service reported no never events in the last 12 months.

The trust had a suicide prevention strategy with a strategic objective to reduce all anchor and non-anchor ligature points by 10% across inpatient and community services, and zero inpatients' deaths by ligature. The trust reported that a most of the mortality cases were at patient’s homes and the cause of death was by ligature. The trust strategy included improving training and awareness towards suicide prevention in collaboration with partner organisations, increased scrutiny of death and improving the way learning from deaths is done to reduce risks of suicide.

We scored this quality statement as 2. The evidence showed some shortfalls. The service did not always work well with patients and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor patient’s safety. They did not always make sure there was continuity of care, including when patients moved between different services

The trust was not always able to offer patients who were referred to or admitted to the service an inpatient bed when required due to a shortage of beds. Staff reported that this was a huge challenge to delivering care and treatment, and as a result they often needed to request for the 136 suites to be decommissioned so that they could be used to provide care for patients who had been assessed and detained under the Mental Health Act 1983. The 136 suite was not an ideal environment to meet patient’s needs for prolonged periods because it was very restrictive and patients were continually being observed which had an impact on their dignity and privacy. The trust told us that the 136 suites had been used as inpatient beds 263 times in the last 12 months with an average length of stay of 90 days. The 136 suites being used as inpatient beds also meant other patients who required the service for brief crisis assessment and support would not be able to access them.

However, staff ensured that all essential information about a patient was received to determine if the patient’s needs could safely be met.

Staff told us they involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.

The trust was working to reduce the number of mental health related concerns for welfare reported to the police under the Right Care, Right Person (RCRP) programme. The RCRP initiative was designed to ensure that individuals with health or social care needs receive support from appropriately trained professionals rather than police officers, except in cases where police involvement was necessary for safeguarding. The trust reported that the number of patients with mental health needs leaving mental health acute hospital before assessment or treatment was completed had reduced in the last 12 months.

However, the trust reported that that the timeliness of patient handovers by other professionals such as the police or ambulance remained below the trust target in the last 12 months.

This service provided a free, 24/7 crisis support for adults and young people across Sussex. Patients who were in crisis could contact the service via NHS 111 Sussex mental health crisis line or text the word “Sussex” to a dedicated number.

We scored the safeguarding quality statement as 2. The evidence showed some shortfalls. The service did not always work well with patients and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving patient’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

The Havens did not operate safely to protect patients from risk of harm and abuse. During our inspection of the Havens, we observed both male and female patients being cared for in the same room while they slept on recliner chairs only separated by curtains. Patients attending the service shared bathroom facilities. Some of the patients who attended the Havens were victims of domestic and sexual abuse. This did not comply with the Department of Health Elimination of Mixed sex Accommodation policy 2010.

The service did not ensure that there were sufficient safeguards in place to protect the risk of sexual and physical abuse to patients who may have had prior experience of such abuse, and the needs of transgender patients. For example, we observed a male patient who had taken their clothes off because the room lacked ventilation and the room was extremely hot. Patients of the opposite sex were also present.

However, across the teams we saw that staff were completing their safeguarding vulnerable adults training and knew how to make a safeguarding referral and did so when appropriate. The service had made 34 safeguarding referrals between March 2024 and March 2025 relating to physical, sexual and domestic abuse, child neglect and acts of omission.

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

While staff working at the Havens knew how to identify adults and children at risk of, or suffering significant harm, they did not receive physical intervention training. Staff reported that there had been occasions when patients who presented to the service displayed behaviours that challenged requiring physical intervention. Lack of training meant they could not always protect themselves and patients from harm.

The service was working towards improving how they responded to safeguarding risks which included working in partnership with other agencies. Leaders across the service met monthly with the trust safeguarding teams and took part in the quarterly safeguarding adult board meetings with other agencies and stakeholders.

Mental Capacity Act

The teams completed their Mental Capacity Act training. Although the Northern West Sussex crisis resolution and home treatment team had a compliance rate of 79%. This was slightly lower than the trust target of 85%.

Staff had a good understanding of the Mental Capacity Act and its five statutory principles. On most occasions, we observed that staff recorded consent to treatment for patients.

The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it.

Staff knew where to get advice from within the trust regarding the Mental Capacity Act, including deprivation of liberty safeguards.

Staff took all practical steps to enable patients to make their own decisions. For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis regarding 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.

The service had arrangements to monitor adherence to the Mental Capacity Act. Staff audited the application of the Mental Capacity Act and acted on any learning that resulted from it.

Staff told us they sought consent from parents or responsible adults before commencing care or treatment. They also ensured to check first if a child or young person was Gillick competent. Gillick competence is a test in medical law to decide whether a child of 16 years or younger is competent to consent to medical examination or treatment without the need for a parent or responsible adult to give consent.

We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with patients to understand and manage risks. They did not provide care to meet patient’s needs that was safe, supportive and enabled patients to do the things that mattered to them.

Staff did not consistently ensure that robust risks assessment were completed for patients who used the service to minimise or remove risks of harm. For example, patients who attended the Havens were required to sleep on recliner chairs. However, staff did not ensure that patients were appropriately assessed for all physical health risks such as venous thromboembolism (VTE) (a condition when blood clot forms in the vein). The National Institute for Health and Care Excellence (NICE) guideline highlights the importance of assessing and reducing the risk of venous thromboembolism (VTE) in adults (over 16 years) in hospital settings due to the associated risks when a person is taking antipsychotic medicines. VTE can restrict or block blood flow, causing damage to tissues and organs and when left undiagnosed, and without timely treatment could lead to serious illness, disability and death.

Staff at the Havens were not trained to carry out restrictive intervention such as the prevention and management of violence and aggression (PMVA) training. Although following the inspection, the trust informed us that staff at the Havens completed the eLearning module on conflict resolution. The service reported 15 incidents of self-harm between March and May 2025. Patients who attended the Havens were admitted because they were in crisis and often needed urgent support. The lack of staff training and up to date operational policy meant that staff would not be equipped to respond to risks of harm appropriately. This meant that both patients using the service and staff could be at risk of avoidable harm.

Staff ensured that patients received a debrief following a restrictive intervention such as a restraint. The service reported 57 instances when patients needed to be restrained at the health-based places of safety to manage their risks in the last 6 months. We saw that patients were offered a debrief following an incident of restraint. Most of the incidents of restraint were to prevent patients causing injury to themselves and others. On one occasion a patient was restrained so that staff could lawfully administer medication to them. We saw that the rationale was clearly recorded, and patient debrief took place following the incident.

Staff enabled patients to give feedback on the service they received through patient surveys, community meetings and give feedback on care. Staff told us they made all efforts to communicate with patients to ensure that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties.

Staff told us they ensured that patients could access advocacy. However, at the time of our inspection, one patient who had been detained under section 2 of the Mental Health Act 1983 for 5 days, had not been referred to advocacy services by staff.

We scored the service as 1 the evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

At the time of the inspection, the Haven at Langley Green hospital was very hot and there was very poor ventilation. One person using the service had to take off their clothes to cool down. Staff told us they could not open the window because it opened into the psychiatric intensive care unit (PICU). There was a risk that high room temperatures, in particularly during the summer months could affect patients and their physical health.

The crisis resolution and home treatment teams at the Department of Psychiatry (DOP) in Eastbourne reported that there was not always enough space to safely deliver care. The clinic room was small which meant that clinical assessment and treatment took place in the Haven.

Although there was closed circuit television (CCTV) operating in the 136 suites and convex mirrors to mitigate the risk to patients using the unit, staff told us that patients on the unit were continuously monitored by CCTV including when they used the toilet. This meant that staff being able to see patients use the toilet and bathroom impacted on their dignity and privacy rights. Patients using the S136 suite at Langley Green hospital did not have a nurse call button in the room in line with the Royal College of Psychiatrists recommendations and Health Building Notes. We shared our concerns with the trust following the inspection, and the trust informed us that following the inspection they had turned off all the CCTV cameras in the toilets and bathrooms across all the s136 suites bar one.

Managers and staff completed risk assessments of the environment to ensure that environmental risks including potential ligature anchor points were adequately managed.

Managers could adjust staffing levels daily to take account of case mix. When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. When agency and bank nursing staff were used, those staff received an induction and were familiar with the service. Managers told us they often used the same members of agency and bank staff who knew the patients well to ensure consistency and continuity of care.

The health-based places of safety including the s136 suites and Havens always had a qualified nurse present as all times.

Following our last inspection in 2019, we told the provider it must ensure that there is adequate medical cover across all teams. On this assessment, we saw that some of the crisis resolution home treatment teams did not have adequate medical staffing. For example, the crisis team at Langley Green had one consultant who worked part-time 3 days a week, and the crisis teams at the Department of Psychiatry in Eastbourne had no medical consultant in the team. Following the inspection, the trust informed us that the crisis team at the Department of Psychiatry had a speciality doctor who was acting up part-time. Staff told us that in case of an emergency the ward doctors would provide support. Lack of medical staffing meant that patients may not always receive appropriate and timely medical support.

The trust did not ensure that staff at the Havens received appropriate training in restrictive intervention such as the prevention and management of violence and aggression (PMVA). However, the trust informed us following the inspection that staff at the Havens had completed the e-learning course on conflict resolution. Staff told us when patients presented with behaviours that was challenging, they would alert the wards who would provide support. The lack of appropriate training meant that staff and patients could be placed at risk and staff would not have the required skills and knowledge needed to manage a difficult situation.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Staff did not always ensure that they took all practicable steps to limit or reduce the spread of infection. For example, the clinic room on Amber ward, that was being used by the health-based place of safety was very dirty, untidy and had an unpleasant odour. Staff told us that the domestic team cleaned the clinic room daily, while the night clinical staff did the cleaning at night. At the time of the inspection, the teams could not show us any cleaning records. There were not always cleaning indicators such as “I am clean” stickers to show when an equipment or furniture was last cleaned. In addition, we saw that the medication room at the Department of Psychiatry, Eastbourne was very cluttered.

While staff at Langley Green health-based place of safety told us that the fridges and clinic room were checked daily, they could not locate the temperature monitoring and cleaning records. In addition, we saw that the medication room at the Department of Psychiatry, Eastbourne was very cluttered.

We scored the service as 1. The service did not make sure that patient’s medicines were managed properly and safely.

Following our inspection in 2019, we told the trust that it must make significant improvements to ensure that policies and procedures for managing medicines were robust and that medicines were managed safely so that patients were not placed at risk. On this inspection, we saw that there remain significant concerns around medicines management across the teams. For example, we reviewed the emergency bag at Langley Green hospital and found that it had not been checked since May 2025. The emergency bag had the wrong tag which required scissors to break it. This meant that in the event of an emergency staff will not be able to quickly access the emergency equipment which could lead to avoidable harm.

At Langley Green, we found one medicine called flumazenil which was used as a rapid tranquiliser had expired in May 2025.

At the Department of Psychiatry in Eastbourne, we saw that staff did not follow the trust’s policy regarding returning medicines to patients. Staff had not given back a person’s medication which was taken from them when they visited the haven. This remained in the clinic room, but the medicine should have been handed back to the person if deemed safe or destroyed. This meant that the person was without their required medicines. Staff at the Department of Psychiatry Eastbourne could not locate the T28 waste exemption certificate (T28 exemption allows pharmacies and similar practitioners to denature controlled drugs, to comply with Misuse of Drugs Regulations 2001).

When patients visited The Havens, staff took their prescription from them which was then transcribed into a medication chart. Staff were then administering patient’s own medication to them. Staff told us that they did this because the Haven was a clinical setting. Staff were not following the trust policy which required that medicines brought into hospital must be reviewed by the admitting doctor who may or may not wish to prescribe them. There were no individualised risks assessments around medicines administration or medicines administration care plans for patients who attended the Havens. Staff could not demonstrate how they promoted patient’s independence around managing their own medicines whilst at the Haven. The impact of not having a robust care and management plans around patient’s medicines could lead to serious injury and death.

The service did not have a clear process to ensure that patient’s medicines were managed properly, and the trust pharmacists did not review patient’s medicines or undertook an audit of patient’s medicines at the Havens.