Sussex Partnership NHS Foundation Trust

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• 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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of regulation 12, Safe care and treatment.

This service scored 38 (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 1. The evidence showed significant shortfalls. The service did not have a proactive and positive culture of safety, based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Staff did not always demonstrate a clear understanding of what constituted a reportable incident, how to report incidents, or the required timescales for doing so. Staff told us they did not always have time to report incidents, as reporting on the electronic system was typically completed by the nurse, regardless of whether they had been directly involved in or had witnessed the incident. This contributed to inconsistencies in reporting and increased the risk that not all safety events were captured.

The ward held daily ‘nursing huddles’ to discuss current risks and how the ward was feeling in terms of safety. However, due to the acuity of the ward and staffing levels, not all staff were able to attend daily huddle meetings due to covering safety on the ward. During the inspection, we observed two nursing huddles, less than a third of the staff on shift were present. This meant not all staff had access to key safety information or the opportunity to have discussions about risk and young peoples’ care.

Staff did not always receive feedback following incidents which limited opportunities for shared learning and improvement. In addition, staff were not consistently offered debriefs or appropriate support following incidents. Staff could not access reflective practice following serious incidents. Staff told us about two serious incidents where they had requested reflective practice. However, there were delays of several months in accessing this due to a lack of facilitators. When a session was eventually arranged, only a small number were able to attend, and no further sessions were offered. Staff we spoke with told us they felt let down by the trust and unsupported following these events, which had a negative impact on morale and their ability to process and learn from incidents. This meant opportunities for reflection, support and learning following incidents were not consistently available or embedded.

However, the trust shared lessons learned from other services within the trust via bulletins.

Staff understood the duty of candour. They were open and transparent and gave young people and families a full explanation if and when things went wrong. Young people told us that after a restraint, staff would speak with them to have a de-brief and see what could have been done differently.

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

The service worked with partner agencies to develop admission pathways. However, these arrangements were not always effective. Managers told us that comprehensive pre-admission assessments were completed with young people, their parents or carers, and community teams to gather essential information before accepting referrals. Despite this, young people were accepted whose clinical needs could not be safely met, and whose needs were not compatible with the ward environment. Post inspection, the trust said these were isolated cases and that assessments had been completed and approved by senor ward-based clinicians. They said the young people’s needs and level of risk subsequently changed, resulting in referrals to other services, with support provided on the ward while awaiting transfer of those young people. This created increased risks of harm and negatively affected the safety, wellbeing and experience of other young people on the ward. Staff also told us they sometimes felt under pressure to accept referrals.

The quality of the service was reviewed by the Sussex provider collaborative for child and adolescent mental health services (an NHS-led Provider Collaborative is a group of providers of specialist mental health, learning disability and services who work together to improve the care pathway for their local population, taking responsibility for the associated budget and care pathway). The provider collaborative met regularly with the service due to ongoing concerns about the care being provided at Chalkhill.

Staff ensured that patients discharge to their local mental health teams was managed safely. We saw evidence that community services were involved in discharge planning. We also attended a multi-disciplinary meeting, where planning for discharge was discussed and included the involvement of families and community teams. This is essential to ensure a smooth and safe transition for young people. The service had a discharge checklist to ensure that all tasks relating to discharge were completed. Leaders highlighted some discharge challenges, noting delays often stemmed from finding suitable onward placements for the young people.

Staff told us they had established working relationships with the local acute hospitals to support young people who required hospital treatment. Staff from Chalkhill liaised with acute hospital staff to reduce waiting times and minimise the length of time young people spent in environments that could be distressing or compromise their safety. Staff from Chalkhill remained with young people while they were in the acute hospital.

We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not share concerns quickly and appropriately.

Young people said they did not always feel safe or supported by staff. They did not always feel listened to or supported when they raised concerns. They said they knew which staff they could push boundaries with and did so which led to them feeling more unsafe on the ward as staff did not consistently manage risks or take prompt action to ensure their safety.

Staff did not always identify or report all safeguarding concerns. They did not always identify different forms of abuse, or the signs associated with these. We saw safeguarding concerns were discussed in shift-to-shift handovers, at huddle meetings and at the daily multidisciplinary meeting and were not raised as safeguarding or raised to the local authority. The trust informed us that they had carried out significant to strengthen safeguarding on the ward however we saw this had not yet been fully effective. Staff did not always take appropriate action to safeguard young people and did not ensure all safeguarding incidents were reported, monitored and responded to in a timely manner to ensure young people were protected from harm.

The service had high use of restrictive practices, and it was not always clear that de-escalation had been attempted prior to young people being restrained or placed in seclusion. Young people told us they felt restraint was used too quickly and not as a last resort. Two young people told us they had been recently hurt by staff during incidents of self-harm and restraint and felt staff did not use correct restraint techniques which hurt them. In response to reviewing restrictive practices on the ward, on the 15 July 2025 the service launched a ‘Reducing Restrictive Practice Panel’ to review individual and environmental restrictions’.

Relevant safeguarding information was displayed on the ward information boards for the young people to see.

Staff received training in Safeguarding Adults (Level 1 and Level 2) and Safeguarding Children Level 3. Staff also completed PREVENT and Domestic Violence and Abuse Training. Staff told us they had access to a range of safeguarding resources on the intranet, and that they could always seek advice and support from senior colleagues such as a clinical lead or matron and the trust safeguarding team.

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

Staff did not always involve young people in the management of risks relating to their care and treatment. We reviewed six young peoples’ care records and observed a shift-to-shift meeting, daily multidisciplinary team (MDT) morning meeting and safety huddle meeting. Young people were not consistently supported to participate and contribute to their care planning and risk assessments.

We reviewed six risk assessments and care plans and observed a shift-to-shift meeting, daily multidisciplinary team (MDT) morning meeting and safety huddle meeting. Most incidents, but not all, relating to young peoples’ presentation and behaviours were recorded in the young persons’ progress notes and then discussed during the meetings. However, these were not always reflected within the risk assessment or care plans for that young person. This meant it was not possible to tell from the young person’s records what their current risks were, what support they needed to manage these risks or how many incidents they had been involved in. Staff did not always document any mitigations or support plans around how staff might support the young person to prevent a similar incident from happening again.

Risk event logs were not always updated by staff and incident reports were not consistently completed following incidents. The service had introduced safety huddles following a learning review into the death of a young person in an acute hospital setting. These safety huddles were intended to provide increased multidisciplinary team (MDT) oversight when there were changes in a young person’s presentation, increased incidents or emerging risks. However, we found the process was not operating effectively in practice. This meant relevant information relating to changes in risk was not always captured or escalated appropriately. Changes in a young person’s presentation or behaviour or increased incidents were not always being identified, monitored, and responded to in a timely way. For example, for one young person, staff discussed how they had been seen responding to visual and auditory hallucinations, going to an area in a room and speaking to someone who was not there. Staff said this had happened on two occasions that week, however this had not been documented anywhere and when we spoke to a member of the MDT, they were not aware and were concerned.

There were blanket restrictions in place on the ward. Restrictive practices were concerns raised by the CQC in June 2023, and the Mental Health Act Review visit in February 2024 and is something the Provider Collaborative also raised as a concern. For example, the courtyard garden was locked throughout the day. We spoke to staff who told us young people could only use the garden with support from a member of staff. We observed a young person alone in the garden, having been left in the garden unsupported and the door being locked. We immediately raised this with a member of staff who unlocked the door and went to check on the young person. Young people were only permitted to use their bedrooms during the day if supported to go upstairs with a member of staff. Young people told us they found this frustrating and upsetting as sometimes they just wanted to relax in their bedrooms, and they could not. There had been multiple incidents of young people being left unattended upstairs where staff had not been aware of the process of supporting them.

Smart phones remain prohibited at Chalkhill. We were told by staff that the use of smart phones was hoping to be piloted at the service, and managers were seeking advice from forensic services regarding this. At the time of our inspection, this had not progressed.

Young people were at risk of harm because they were able to bring contraband items onto the ward. During a safety huddle meeting, staff discussed having found a vape on the ward that morning, another staff member reported observing a young person in possession of that vape the day before, that had reportedly been brought back onto the ward following their leave. Staff discussed how the young person had not been asked to hand the vape in as they were concerned doing so could upset the young person and lead to an incident. The following day, we found no evidence documented what action had been taken following the discovery of the vape, including whether the item had been safely removed or whether risk assessments had been reviewed. This meant there was not always clear oversight or assurance that risks relating to contraband were being managed consistently and safely or documented appropriately.

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.

The layout of the ward across two floors meant that staff could not always observe young people in all parts of the ward. This was because bedrooms were on the upper floor and communal areas and the nursing office on the lower floor. The nursing office was located away from the communal areas, at the back of the ward and on the first day of our inspection it was brought to our attention that the door in the corridor leading to the nurse’s office was being kept locked to prevent young people from getting near to the office. Staff and young people told us this was because of repeated incidents of young people pushing their way into the office when staff opened the door. However, we observed young people trying to get staff attention from staff in the nursing office and waiting in the corridor, with no staff available on the ward to support them. We raised this as an immediate concern and was assured this would be reviewed. On the second day of our inspection, we noted the door to be unlocked.

The ward had two gardens, the main garden and the courtyard garden. The main garden had been closed and subsequently redesigned for the young people. However, it had to be closed again as appropriate due diligence checks had not been completed and the garden planning had not been undertaken appropriately when considering the young peoples’ needs and risks. In particular, it was identified that the soil in the raised garden beds contained sharp shards and debris, presenting a potential risk of harm to the young people through self-injury. Furthermore, blind spots behind the raised flower beds had not been identified or mitigated in the planning and were only identified once works had been completed. In addition, a garden shed had to be removed as it presented as a potential climbing risk for young people. These demonstrated that risks and safety considerations for that service had not been effectively assessed or appropriately planned or mitigated and impacted the young people on the ward as continued delays meant they could not safely access that outside space.

There had been a number of incidents where young people had been left upstairs in the bedroom area, without staff support or supervision, despite the ward process and bedroom doors being identified as a ligature risk. Staff told us and we saw from the ward process documents that staff should remain upstairs whenever young people were in the bedroom area in order to mitigate and monitor the risk. The repeated incidents demonstrated that identified environmental risks were not always consistently managed in practice.

However, the environmental risks that existed had been appropriately identified by staff. The nurse's office had a heat map and photographic examples of ligature risks. This included a form for recording risks and an associated action plan, covering all areas of the ward and external areas. Staff completed risk assessments of the ward, including daily environmental walk around checks, and removed or reduced any risks they identified, such as reporting damaged items to maintenance.

Closed circuit television (CCTV) was in place in communal areas on the ward. CCTV was not monitored constantly, but viewed retrospectively, for example, when investigating an incident. Bedroom were fitted with anti-barricade doors and anti-ligature features. Bedroom doors had vision panels on them to enable staff to carry out observations from outside bedrooms, without the need to always open the door and disturb the young person.

The ward had a seclusion room which allowed clear observation and two-way communication and had toilet facilities and a clock. The seclusion area was also used as an enhanced care area when required, as it could be closed off from the main ward. The flexibility meant the ward was able to provide a safe and adaptable environment in response to any young person’s needs and level of acuity.

Staff had easy access to personal alarms and young people had easy access to nurse call systems in their bedrooms.

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

We scored the service as 1. The evidence showed significant shortfalls. The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs

There were not enough permanent staff, and several staff were due to leave imminently. The service was without a ward manager, and the matron was on secondment to another post. As a result the two Clinical Nurse Specialists were having to support ward management, which affected their ability to carry out their own roles. The lead nurse was due to leave the week of our inspection and two Band 5 nurses had handed in their notice. On speaking with staff, we were made aware that other staff were planning to leave. The Responsible Clinician (RC) was due to leave a few weeks after our inspection, leaving only one ward doctor remaining. Attempts to recruit an RC to the role had not been successful.

At the time of inspection, there were vacant posts at the service, this impacted staff morale. These roles were out for advert at the time of inspection, leaving remaining staff under extreme pressure and affecting the quality and safety of care the young people needed. There was only one part-time Occupational Therapist who was supported by an activities coordinator and a part-time Psychologist, who was only able to see two young people each week. There was no family therapist in post.

Staffing levels were not always sufficient to meet the needs of the ward. On some shifts, staffing levels were lower than the identified number of staff needed due to staff sickness or difficulties in securing bank or agency staff cover. Both staff and the young people raised concerns that the ward was not safe.

The ward was short staffed on both days of our inspection. During handover, there were nine staff present, including two nurses and seven support workers. Staff discussions showed they were unclear about the current staffing levels required, with some staff stating there should be 10 staff and some saying 11 staff are required on duty. It was later confirmed that 11 staff should be on duty to support the clinical needs of the young people on the ward. One agency member of staff arrived later that morning, but the shift remained one member of staff short.

There were high levels of agency and bank staff working at Chalkhill and unfilled shifts due to staff shortages. Between 23rd August 2025 and 27 August 2025, bank and agency staff made up between 50% and 100% on shifts across nursing staff and support workers. Staff told us the ward was often short staffed and there was immense pressure on substantive staff due to high agency and bank staff use, including not having enough staff to respond to incidents, agency and bank staff not always being familiar with the service users’ needs and not always aware of ward process and trust policies.

There was not always enough staff deployed on shift with the appropriate knowledge, skills, experience and competence to meet the needs of all the young people safely. The service had not completed assessments of staff competence, and feedback from staff, the young people and incidents, demonstrated that not all staff knew how to safely support the young people. Staff told us that there was a high staff turnover, sickness and vacancy levels across the ward. Young people and staff told us they felt more staff were needed to ensure that they could provide better therapeutic support and more one to one time.

Staff could not carry out physical interventions safely. Agency staff and trust substantive staff were trained in different methods of restraint, known as Prevention and Management of Violence and Aggression (PMVA). This placed staff and young people at potential risk of harm during restraint as different techniques were being used. The trust was aware of this concern and no action had been taken to resolve it.

Although managers were expected to provide supervision, appraisal and professional support, all staff we spoke with told us they did not receive regular supervision, largely due to pressures on the managers and the ward and therefore supervisions being cancelled. Staff morale was low and they did not feel adequately supported in their roles.

However, staff were up to date with their mandatory training.

There was adequate medical cover. In working hours, the service had enough medical cover and doctor’s available to attend to any emergency. The ward had one permanent, full-time, child and adolescent mental health consultant. The ward had a full-time speciality doctor. Out of hours medical cover arrangements were in place to deal with emergencies.

There was one part-time Occupational Therapist who was supported by an activities coordinator and a part-time Psychologist, who was only able to see two young people each week. There was no family therapist in post.

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.

Staff told us they received training in infection prevention and control. They knew what their role was in preventing infection. This included hand washing prior to entering the ward, regular environmental checks and implementation of cleaning regimes.

The ward had a dedicated housekeeping team. They ensured that general cleaning records were current and that the premises were kept clean.

Staff completed infection prevention and control checks and audits to ensure required standards were met. Staff had access to an infection prevention and control policy and support from infection prevention and control leads within the wider trust.

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 young people’s needs, capacities and preferences. However, they did involve young people in planning.

Controlled drugs records and the registration of the location for the denaturing of controlled drugs were complete. However, staff were not consistently following the service's processes for the management and oversight of controlled stationary which are record books used to document controlled drugs. Whilst there were signs highlighting the storage of medical gases, staff were unable to provide assurance that the policy was being followed.

Prescribed medicines were reviewed by a pharmacist allocated to the service. Young people told us they were able to ask questions about their medicines they were prescribed, or staff were considering prescribing to them. Relevant Mental Health Act (MHA) documents were stored with the prescription charts. This allowed staff to review then MHA documentation when prescribing, administering and reviewing medicines. Each young person had a further record; this record included a paediatric early warning system (PEWS) observation and escalation chart and other physical health monitoring for example their weight. The frequency of this monitoring was based on the young person's needs and their prescribed medicines. These records also included bespoke young person records for specific medical conditions and treatments.