- SERVICE PROVIDER
Sussex Partnership NHS Foundation Trust
This is an organisation that runs the health and social care services we inspect
We served a warning notice on Sussex Partnership NHS Foundation Trust on 11 July 2025 for failing to ensure that the care and treatment of patients who used the mental health crisis services and health-based places of safety received care that was consistently safe, appropriate, met their needs, upheld their privacy and dignity rights and protected them from avoidable harm.
The governance systems in place were not robust and did not provide adequate oversight and ongoing monitoring of the quality and safety of care provided. Our concerns relate to the following locations:
Assessment report published 28 October 2026
Contents
Ratings - Acute wards for adults of working age and psychiatric intensive care units
Our view of the service
We carried out an inspection of the acute and psychiatric intensive care units of Sussex Partnership NHS Foundation Trust on 7, 8, 9 October 2025. We undertook this inspection following information of concern we had received about the low staffing levels, excessive use of restraint so that patients would take their medicines, staff not always involving patients and their families in their care at both Langley Green and Mill View Hospitals and cleanliness and poor maintenance of the premises at both Mill View and Meadowfield Hospitals.
We visited 3 locations and 7 wards in total. We visited 3 wards at Mill View hospital which included Palmeira ward (a female only acute ward), Pavilion (a male psychiatric intensive care unit) and Falmer ward (a mixed gender acute ward for adults). At Meadowfield Hospital, we visited 2 wards which included Rowan ward and Maple ward (both mixed gender acute wards), and Langley Green Hospital which included Jade (a mixed gender acute ward) and Amber ward (a mixed gender psychiatric intensive care unit). Meadowfield Hospital was last inspected in 2016 and rated requires improvement. We carried out a focused inspection at Mill View Hospital in May 2024, which the service was rated requires improvement. Langley Green Hospital was last inspected in April 2021 where we carried out a follow up inspection to assess whether the warning notice we issued in February 2021 had been complied with. This inspection was not rated.
At this inspection we found the service to be requires improvement. The service was in breach of Regulation 10 (Dignity and respect). The wards did not always comply with the Mental Health Act Code of Practice in relation to eliminating mixed-sex accommodation. We found the service to be in breach of Regulation 12 (Safe care and treatment) because the trust did not always manage medicines safely and when patients were administered medicines for rapid tranquilisation, staff did not always carry out the required physical health assessments which put patients at risk of harm on both Amber and Flamer wards. On Jade and Maple ward there was no system in place for patients to ask for help in an emergency. The service also did not manage ligature risks appropriately. The service was also in breach of Regulation 13 (Safeguarding service users from abuse and improper treatment) because we found that blanket restrictions which was in place on Rowan, Mapel, Jade, Amber, Palmiera and Falmer wards were not proportionate to the risks posed to service users and were not effectively monitored.
The service was also in breach of Regulation 18 (Staffing). The provider did not always meet the required staffing establishment for the wards to keep patients safe. We identified a breach of Regulation 17 (Good governance) because the trust’s own governance systems in place were not robust and failed to identify where improvements were required, including those that CQC had identified at the time of inspection.
The trust had not ensured that the service appropriately recorded and monitored the use of blanket restrictions. At Mill View hospital, issues identified at the last inspection continued to persist such as the unsafe and inappropriate administration of medicines. The trust had not always completed and recorded physical health checks and physical health monitoring of patients following the administration of rapid tranquilisation. Post-dose monitoring following rapid tranquilisation was incomplete in several cases.
The trust still did not always detect and manage potential ligature risks in the care environment. We found ligature risks on Amber ward that had not been recorded on the ward’s ligature risk assessment.
The service did not have enough staff to provide safe care and treatment to patients. Patients, staff and carers felt the staffing establishment on all wards was not adequate to provide safe care.
The service did not have a clear system of accountability and good governance processes in place. The provider’s blanket restrictions policy was not regularly reviewed and was not part of the provider’s governance arrangements. The provider’s own oversight audits failed to identify areas for improvement that we had identified during our inspection or failed to enact improvement. The length of stay for patients varied on different wards.
However, the service ensured that staff reviewed do not attempt cardiopulmonary resuscitation (DNACPR) decisions on admission and involved patients in the decision.
Carers were involved in the care of their relatives when appropriate.
Staff provided a range of treatment and care for patients based on national guidance and best practice. The ward team included or had access to the full range of specialists required to meet the needs of patients on the ward. Staff from different disciplines worked together as a team to benefit patients.
Patients’ needs were met through good organisation and delivery. The design, layout, and furnishings of the ward supported patients’ treatment, privacy and dignity. Staff supported patients with activities outside the service, such as work, education and family relationships.
Staff helped patients with advocacy. The service acted on concerns and complaints, investigated them and learned lessons. The service made it easy for patients to share feedback and ideas, or raise complaints about their care, treatment and support.
We have asked the provider for an action plan in response to the concerns found at this assessment.
People's experience of this service
We spoke with 34 patients who were generally not happy with the blanket restrictions they faced on the wards and the need to ask staff for snacks and drinks. Patients told us that due to staff shortages it could sometimes take a while for staff to provide them with drinks and snacks once they had requested them.
Some patients felt there were not many activities on the wards and that they could not always utilise their section 17 leave due to staff shortages. Some patients said there was often no staff presence in the communal areas of the wards, especially at night, which made them feel unsafe. Some patients expressed not feeling safe on the wards because some staff slept while on night duty and they had experienced theft of their belongings. Most patients on Maple and Rowan wards felt the wards were unclean. Some patients told us that they were unhappy about the lack of involvement in developing their care plans. Discharge was also a problem for some patients due to difficulties in finding suitable accommodation that met the patients’ needs. One patient said they were not happy with the length of time they had to stay on the ward.
However, patients received debriefs with staff after an incident. Patients felt their complaints were usually resolved by the managers. Patients said staff were kind, caring and compassionate and that they took an interest in their wellbeing and supported them to recover. Patients said staff worked with them to maintain contact with their families and carers, and that access to an advocate was straightforward. Some patients felt the food was great and they had a choice. Fifteen carers we spoke with across the 7 wards visited gave us mixed feedback about the service. Carers said that staff were respectful, visible, and committed to patient care. Carers named individual staff members who were ‘excellent’ and ensured carers were involved in care planning and medication reviews. One carer praised the services’ family liaison officer for their good work in helping them connect with their family. However, some carers raised concerns about staffing shortages, inconsistent communication, limited access to activities particularly at weekends as well as the cleanliness of the environment, and unmet physical health or accessibility needs for patients on Falmer and Amber ward. Two carers raised concerns about limited therapy for the patients. Some carers also told us that food quality and choice varied, and information about carers assessments was rarely provided.