Sussex Partnership NHS Foundation Trust

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Are services Well-Led? This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question as requires improvement. At this assessment, the rating remained the same. We rated the key question as requires improvement because the trust had not ensured that there were robust governance processes and procedures in place that supported the running of the service. Staff were not always able to explain how the Havens operated, and how they aimed to meet patient’s needs. The service was unable to maintain oversight of the quality and safety of care being delivered because there was no effective system in place to monitor it. This impacted on patients being able to receive safe and effective care that met their needs.

The service was in breach of Regulation 17: Good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 61 (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 2. The evidence showed some shortfalls. The service did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of patients and their communities.

The Trust described the Havens as a 24-hour nurse led service where patients over the age of 18 who were in crisis could be assessed and get support when they were experiencing a mental health crisis. Accessing this service was by referral and patients were only supposed to stay for no longer than 23 hours. However, staff who worked at the Havens could not clearly explain how the service operated to meet patient’s needs and how this was aligned with the trust’s overall vision and strategy. Staff were not always aware of the key operational policy in place for the Haven’s as it had not been finalised by the trust. The service did not consist of a multidisciplinary team. Staff shared their concerns about how the service was operating. For example, we observed that some patients attending the service brought their own medicines, which was then transcribed into a prescription chart and administered by staff. The patients and their medicines were not always reviewed by a medical doctor or a pharmacist. Staff felt the Haven was a holding unit where patients could stay indefinitely without a legal framework, although the patients were informal and could leave at any time.

Some patients stayed for a long time in Section 136 suites, because a bed on an adult acute mental health ward could not be identified for them in a timely manner. The trust reported 263 cases where the detention under Section 136 of the Mental Health Act had expired and there was no longer a legal framework to hold the patient in hospital for treatment in a suitable environment that could meet their needs. This was not in line with the trust’s vision and strategy to deliver consistently reliable and high standards of care that met patient’s needs.

Staff across the crisis resolution home treatment teams were able to describe their service, their roles and responsibilities and how the teams worked together to meet patient’s needs. The teams were able articulate how the service delivery aligned with the overall trusts vision and strategy.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff across the teams spoke very highly of their managers. Leaders felt proud and spoke very positively about their teams. They recognised the challenges and pressures the teams face.

Service leaders including managers demonstrated the skills, knowledge and experience to perform their roles. They were very passionate about their services and wanted to do a good job.

Leaders were visible in the service and approachable for patients and staff.

Leadership development opportunities were available, including opportunities for staff to grow in their career.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where patients felt they could speak up, and their voice would be heard.

Staff felt they could raise concerns without fear of victimisation. Staff felt they had a voice that counted, as indicated at the trusts most recent NHS staff survey conducted in 2024.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Feedback could be provided via the friends and family test and patient’s experience surveys. For example, from the 2024/2025 survey conducted by the trust 90% of patients reported that staff discussed their medication with them. The service was performing around national average for most indicators such as giving patients a choice of how their care and treatment will be delivered and having a care plan.

Patients and carers were involved in decision-making about changes to the service. Patients and staff could meet with members of the provider’s senior leadership team and governors to give feedback.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for patients who work for them.

Staff felt that the trust and service promoted a culture of openness and inclusion.

The teams had equality and diversity champions within who worked to ensure that the voices of patients such as those from minority ethnic groups and LGBT+ staff were heard.

Staff were able to apply to work flexibly to help with personal circumstances such as caring responsibilities and health issues. Managers put reasonable adjustments in place for staff members to help them carry out their role.

The trust undertook equality monitoring of staff within the service to ensure diversity in its make-up and representative of the patient groups. The service was actively working towards addressing ethnic inequalities in healthcare and promoting an anti-racist organisation and this was reflected in its recruitment strategy. For example, over 18% of staff were from minority ethnic groups.

We scored the service as 2. The evidence showed some shortfalls. The service did not always have clear responsibilities, roles, systems of accountability governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The service did always operate effective governance processes to ensure that the care being delivered to patients was person centred and safe, with clear procedures for staff to follow. We reviewed the clinical governance meeting minutes for February, March and April 2025 and found that no discussions had taken place regarding The Haven’s and the overall running of the service. The meeting minutes did not include information relating to the patients who had stayed longer than the 23-hour admission period and how they were working to address the barriers that were preventing patients from being transferred. Many of the patients that were admitted to the service required a level of care and treatment that the setting could not provide and could only be met on an inpatient acute mental health ward. This meant that some patients stayed at The Haven’s for significant periods of time.

The trust did not carry out routine audits that related to monitoring of quality and safety of the service. The service had not identified poor practice relating to medicines management, a lack of care and treatment plans and patients being required to stay in mixed sex accommodation which put patients at risk of sexual safety incidents.

The Haven's did not have a ratified operating procedure in place at the time of our assessment. This impacted on overall running of the service as staff did not have a protocol to refer to. For example, staff did not ensure that they initiated a specific care plan for a patient who had been admitted for longer than the 23-hour period. Staff did not ensure that patients breaching the maximum admission period was reported as an incident.

The trusts Section 136 suites were frequently being used as inpatient beds due to the difficulty in identifying suitable beds in an inpatient mental health setting for adults. The trust did not have a clear procedure in place for staff to follow that clearly described how staff would ensure that the patients who were no longer detained under S136 of the Mental Health Act (MHA) 1983 would continue to receive high quality care, that is person-centred and informed by the most appropriate clinical decisions within a reasonable timeframe. The lack of clear and robust guidance to support staff in how to manage a patient in these circumstances, increased the risk of patients not receiving person-centred care in an environment that met their needs.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for patients. They shared information and learning with partners and collaborated for improvement.

The trust and directorate leaders engaged with external stakeholders such as commissioners, police, the Ministry of Justice and the probation service, social services and Healthwatch and other third sector organisations and charities.

There was a monthly Multi-Agency Public Protection Arrangement (MAPPA) meeting that took place, involving several external stakeholders to discuss individual cases, which was an effective joined up multi-agency approach to manage patients known to mental health services, who could be a risk to themselves, and or to others.

There was a data sharing agreement in place between the trust and the integrated care board (ICB) to enable clinical reviewers, to review the care delivered by the service. This enabled the ICB to identify those patients entitled to s117 aftercare and to ensure those patients were provided with this care as appropriate.

The service ensured that incidents were reported appropriately to external agencies and third-party organisations including the Care Quality Commission (CQC), the Coroner’s Office, the Police and the ICB.

Patients and staff could meet with members of the Trust’s senior leadership team and commissioners to give feedback.

We scored the service as 2. The evidence showed some shortfalls. The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for patients. They did not always actively contribute to safe, effective practice and research.

While there were no ongoing quality improvement programmes specifically for this service, we saw that the trust was piloting several quality improvement programmes across the other services and wards.

The service was not part of any quality network, and the teams were not working towards any professional accreditation.

Managers did not ensure that they consistently reviewed complaints and lessons were learned. For example, we reviewed two separate complaints from a patient about delays in getting their prescription. However, we did not see any investigations to ensure lessons were learned and appropriate mitigations were in place.

Although, managers told us they encouraged staff to consider and discuss opportunities for improvements and innovation.