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

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 remained the same. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. 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 assessment on patients on Amber, and Falmer wards which put patients at risk of harm,and 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 in place on the 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. The service was also 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.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff we spoke with could describe what incidents were and knew how to report them. Staff raised concerns and reported incidents, serious incidents and near misses in line with policy. All staff knew what incidents to report and how to report them. We reviewed the service's incident log which confirmed that this was the case.

Leaders investigated incidents where appropriate. Investigation reports were thorough and addressed all points raised.

Staff could give examples of changes implemented because of learning from safety incidents. For example, modifications were made to the bedroom doors after a ligature risk was identified. Staff told us the risk was rectified promptly, learning was shared and the ligature risk assessment updated. Learning was also identified from another incident that related to missed doses of medicines on Falmer ward in June 2024. Leaders involved pharmacy colleagues and implemented a new process in July 2024. This process was effective in decreasing the number of medicine errors.

Staff discussed incidents and lessons learnt in several forums, including supervision, daily huddles, team meetings and reflective practice. Staff were informed about learning from the wider organisation through the provider’s newsletters. This information was shared with bank staff through group supervision.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation when things went wrong.

Patients were able to raise concerns, provide and receive feedback on issues that impacted them. The weekly community meeting included an update on actions, safety concerns, environmental issues and “you said, we did” feedback. Three patients we spoke with told us they received a debrief with staff after an incident.

Most carers said they felt reassured that staff took their safety concerns seriously and took actions promptly.

Staff were debriefed and received support after a serious incident. Incident investigations we reviewed confirmed that staff were debriefed and offered support after a serious incident. An employee helpline was available for additional support. However, one member of staff on Rowan ward said they were not debriefed following incidents.

Incidents were reported promptly and investigated by managers in line with the policy, with learning documented and relevant actions updated in care records.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met.

Patients experienced long length of stays in hospital. The average length of stay on the wards was 56 days. Jade ward had a lower average length of stay of 31 days. Three patients on Jade ward had stayed on the ward for more than 100 days. This was sometimes due to reasons outside of the trust’s control such as delays in finding appropriate social housing accommodation for patients, a lack of community placement funding and lead practitioners available to facilitate the discharge process. Records also showed that patients had to wait for an extended time to access an inpatient bed whilst in the community.

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. For example, staff told us about comprehensive discharge planning meetings where family, the MDT and external people involved in the patients' care attended. Staff said that there could be delayed discharges due to issues in securing accommodation. Staff said they ensured that patients discharge to their local mental health teams were managed safely.

Blanket restrictions in place were not always proportionate to the risk of harm posed to the patients and they were not routinely recorded and monitored. At the time of our inspection, we found that Rowan, Maple, Jade, Amber, Palmiera and Falmer wards had blanket restrictions in place. There were no cups available in the dining room on Rowan, Jade and Maple wards and patients did not have free access to hot/cold drinks or snacks on all wards because the cupboards were locked. Thirty out of 34 patients we spoke with told us they were unable to access drinks and snacks without asking staff. Five patients said that due to staff shortages on the wards sometimes it could take a while for staff to attend to their request for drinks and snacks. There was no record or log to explain why the blanket restrictions were in place. Staff told us that there was blanket restrictions in place due to risks posed by patients on various wards.Patients' rooms were searched weekly. The rationale for the searches was to minimise contraband items entering the clinical environment that could pose a risk to the individual or other patients. Following our inspection the managers at Meadowfield Hospital had implemented a new standardised blanket restriction log so that the recording of restrictions was consistent across all wards. Managers showed us a copy of a new template they planned to introduce to record and log blanket restrictions.

Patients did not always feel safe on the wards. Twenty four out of 34 patients we spoke with told us they felt safe on the ward and 10 patients told us they felt unsafe. Three out of 6 patients on Amber ward made allegations about their personal items being stolen from their lockers and from their bedrooms which was only accessed by staff on duty. This was fed back to the management team during our feedback session with the provider.

Whilst patients did not always feel safe on the wards, the service did have systems and policies in place to safeguard and protect the patients from harm. Safeguarding was part of the induction programme for new members of staff and ongoing mandatory training. Most eligible staff had completed mandatory safeguarding training.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. For example, staff used the chosen name and pronouns of a transgender patient.

Staff we spoke with knew who the safeguarding lead was and how to report safeguarding concerns. Safeguarding was discussed in a variety of forums, including daily and weekly meetings, ward meetings, handovers and clinical and managerial supervision.

The service had a safeguarding lead who worked closely with staff to improve their understanding of safeguarding. Staff said they felt well supported in this area.

Staff followed safe procedures for people visiting the service. All wards had a visitors room and visits could take place throughout the day except during protected times such as meal and medicine administration. The ward did not allow children to visit the wards. They were required to use the visitors room located outside of the wards.

Mental Capacity Act

Eighty seven percent of staff across Rowan, Maple, Jade, Amber, Pavilion, Palmeira and Falmer wards had received training in the Mental Capacity Act and deprivation of liberty safeguards. Staff had some understanding of the Mental Capacity Act, particularly the five statutory principles.

On Rowan ward, we reviewed leave forms for patients and found that a patient was initially denied their leave because the responsible clinician (RC) was on emergency leave and could not review the patient. The RC for other wards was also not available. We found that on one occasion the patient had been able to take their leave without the RC’s appropriate authorisation. This presented a potential risk to the patient and others.

There were no DOLS applications (safeguards to protect people without capacity to make decisions about their own care.)

The provider had a policy on the Mental Capacity Act, including DOLS. Staff were aware of the policy and how to access it. Staff knew where to get advice from within the service regarding the Mental Capacity Act. They spoke to the qualified staff or contacted the Mental Health Act office for advice and guidance.

Staff took practical steps to enable patients to make their own decisions. Most patients were involved in the development of their care plans, risk assessments and personal behavioural support (PBS) plans. PBS is a person-centred, proactive strategy to understand and manage distressed behaviours, focusing on improving quality of life for individuals with learning disabilities or autism. Patients told staff what their triggers were and how best staff could support them at difficult times.

For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. Staff did this on a decision-specific basis regarding significant decisions. We reviewed 26 patient records and saw that staff had routinely carried out assessments of capacity for consent to treatment.However, staff had not completed capacity assessments for 3 patients who appeared to lack capacity for treatment on Rowan, Mapel and Palmeira wards.

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. For example, a patient who disagreed to take their physical health medication had their medication administered to them covertly. Staff held best interests meeting with the relevant professionals and family members and involved their family in developing their medication care plan.

Staff knew how to make deprivation of liberty safeguards applications if required in the future.

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. The Mental Health Act administrators sent emails to the registered clinician and nursing staff where corrective action was required.

Staff did not always review and update risk assessments following an incident. We reviewed 26 risk assessments across all wards we visited and found that care plans and risk management plans were not always updated with new information following an incident. For example, staff had not updated the care plans of 5 patients following an incident and there was no risk management plan in place for 6 patients. This meant that there was no agreed plan in place that set out how a patients identified risk would be mitigated and managed, which could result in staff not being able to respond in a way that prevents the patient coming to harm.

Staff assessed and managed risks to patients and themselves and followed best practice in anticipating, de-escalating and managing distressed behaviour. Staff knew about any risks to each patient and acted to prevent or reduce risks. Staff shared key information to keep patients safe when handing over their care to others. Shift changes, handovers and multidisciplinary meetings included all the necessary information relating to patients. The service provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There were clear procedures for supportive observations and engagement, staff we spoke with knew these. Observation records were complete and accurately maintained. Staff demonstrated a clear understanding of observation levels and carried out intermittent observations at random intervals in line with provider policy. However, one staff member on Jade ward told us they did not have breaks in-between observations.

Staff ensured that patients could access advocacy. For example, all patients had access to an advocate and an independent mental health advocate (IMHA).

Staff searched patients when they returned from leave to ensure they were not bringing any contraband items onto the wards. Patients were searched in the air lock area of the wards to protect their dignity.

Whilst staff had completed risk assessments of the care environment, we identified several ligature anchor points that did not have robust mitigations in place. We found potential ligature anchor points on Rowan ward at Meadowfield Hospital such as curtain tracks, radiator covers, window handles in the community area and door handles in the garden area. This was fedback to the management team during our feedback session and we were informed that the service was aware of the ligature risks and they were recorded on the ligature risk assessment. Despite the ligature anchor points being recorded on the ligature log, there were no actions or indication of when the ligature risk would be eliminated. In the ligature log, we found recorded statements such as ‘not started’ for some identified ligature risks.

Although it was recorded in their ligature risk assessment that mitigations to manage these risks were in place because staff were expected to observe these areas routinely, this did not always happen because staff were sometimes asleep whilst on shift. For example, 6 patients and one staff member reported this to us at the time of inspection. This concern was fed back to the management team during our feedback session.

Ward layouts did not always allow staff to observe all parts of the ward environment. We found that staff had good lines of sight on Maple and Rowan wards. Staff were stationed at central points on each ward. The layout on the other wards such as Amber ward did not allow staff to observe all parts of the environment. Amber ward had the nursing station looking into the communal space but there was no clear line of sight to the bedroom corridor. There was a large dome mirror in the middle of the ward which gave staff line of sight into some parts of the bedroom corridor, but not all the bedroom corridors could be observed. This could put patients at risk of harm.

Managers told us that they had requested to have mirrors and CCTV installed in the past but were informed it was the Trusts’ policy not to have CCTV in place in the open areas of the ward apart from the seclusion rooms.

Most ward areas were clean and had good furnishings. Patients and carers told us the ward environments at Palmeira, Jade, Amber, and Rowan wards were well maintained and comfortable with a good atmosphere. Patients and visitors could relax and access outdoor space and quiet rooms. However, Pavilion and Maple wards looked tired and needed redecorating. Two carers told us patients’ rooms were not cleaned regularly. Painters had begun redecorating Maple ward during our inspection.

Patients had wrist bands which granted them access to their bedrooms.

The wards did not comply with guidance on eliminating mixed-sex accommodation. Jade, Rowan, Falmer, and Maple wards were mixed gender wards.Rowan ward had two single-sex corridors (one male and one female) and a separate three-bedroom corridor. This flexible corridor was designated for patients of any sex, according to demand and capacity on the ward and the bedrooms all have ensuite facilities. At the time of our inspection, we found that one male patient had been incorrectly placed on a female corridor. The female patient was receiving support from staff and their bedroom door was open and they were visible to other patients on the ward. This impacted the patient’s privacy and dignity. We raised our concerns with the trust who told us that the service had a protocol in place such as enhanced observations to manage incidence of when patients go into the opposite sexes’ accommodation area. Managers also informed us the trust had clear policies and procedures on how to respond to these types of incidents and that staff had received additional sexual safety training to manage sexual safety concerns effectively.

Patients did not always have access to a call bell system where they could raise the alarm in the event of an emergency. On Jade and Maple ward there was no system in place for patients to ask for help in an emergency. Patients on Jade and Maple ward did not have access to a mobile or fixed call bell system. We found that only the accessible bedrooms had a nurse call system in place. Maple ward had call bells in bathrooms but not in bedrooms.

The wards that did provide a call system, we observed staff responding to alarms in a timely manner during our inspection. All staff carried personal alarms.

Rowan and Jade wards did not have a seclusion room but accessed the place of safety when there was the need to seclude a patient.

Most seclusion rooms we visited during our inspection allowed clear observation, two-way communication, had toilet facilities and a clock. Staff completed detailed recording forms which were uploaded to the electronic recording system for each patient while they were in seclusion. Amber ward’s seclusion allowed clear observation into the room because there was CCTV in Amber Ward’s seclusion suite and provided full visual coverage which mitigated blind spots.

Both Pavilion and Amber wards were able to provide patients with an ‘extra care’ area. An extra care area is a specialised, low-stimulus space on a mental health ward designed to safely nurse a single, highly distressed patient away from the main clinical area. The space is intended to provide a calm environment and as an alternative to seclusion. On Amber ward, staff told us that the door to this area was not locked as it was not a seclusion room and patients were always accompanied by a member of staff.

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

Prior to our inspection, patients, families and staff raised concerns about staff shortages which impacted on the care they could provide to patients. During our inspection we identified that there was not always enough staff to support patients to utilise their section 17 leave, provide meaningful activities and effectively meet patients’ needs.

As of September 2025, staff vacancy rates ranged from 0% to 31%. Pavillion ward had the highest vacancy rate of all the wards we visited. Turnover also ranged from 10.8% to 28.1%. Falmer ward had the highest turnover rate. Sickness rates ranged from 1.1% and 9.9%.

Senior managers agreed the wards were under established because the number of staff deployed to work on most wards did not match the required expected numbers of patients to staff ratio to keep the wards safe. The trust had calculated what the safe staffing levels should be for each shift on each ward, and that there were always enough staff rostered to provide these safe staffing levels on every shift.Managers told us the provider was addressing the staffing establishment problem through a staffing optimisation programme. They were submitting data to the MHOST (Mental Health Optimal Staffing Tool) for review.

Staff and managers across the wards told us they struggled with the staffing numbers deployed to work on all wards to deliver safe care to patients. Although the trust had calculated what the safe staffing levels should be for each ward, we received feedback from 4 staff on Amber ward, 3 patients on Amber, 3 patients on Falmer and 3 patients on Palmeira wards who felt that there were not enough staff to meet the needs of patients However, staff on Pavilion ward informed us the staffing levels were sufficient to be able to deliver safe and effective care to patients.

Staff shortages sometimes resulted in staff cancelling escorted leave and ward activities. Staff told us low staffing levels sometimes had an impact on staff spending time with patients, patients being able to use their Section 17 leave as well as staff supporting ward activities. Three staff we spoke to said low staffing levels on the wards also affected staff’s ability to complete paperwork and effectively meet patients’ needs. Staff felt acuity of patients had increased. One staff member told us that they did not have the time to report an incident.

Staff felt senior managers listened to them and had been holding discussions about their concerns regarding the staffing levels. However, nothing had been done to resolve their concerns. Staff told us duty shifts were not always filled and were unaware of any action being taken by managers to address this.

There was a lack of psychology and occupational therapy (OT) input for prolonged periods of time for some wards. For example, Langley Green and Mill View did not have a psychologist. All other clinicians were locum. There was a high turnover of managers on Falmer ward and there had been 6 new managers on the wards we visited within the last one year.

Four staff we spoke to on Amber ward felt burnt out due to low staffing numbers and the high use of bank/agency staff who the staff said did not know the wards well. Three patients out of 6 on Amber ward said they usually found one member of staff present within the communal areas. Two patients on Palmeira ward said often there were no staff in the open areas of the ward. One staff member told us patients informed them they did not feel safe on the ward at night sometimes because there were fewer regular staff deployed to the ward which patients did not know and this had an impact on their wellbeing. On the day of our inspection, we found 2 agency staff deployed to work on Amber ward but one told us they did not have good knowledge of the ward. This impacted staffs’ ability to engage with the patients and make them feel safe.

Three patients out of 6 on Falmer ward said they could not regularly access their section 17 leave due to unavailability of staff to escort them.

Staff informed us there were not enough MDT team members to cover the wards. For example, there was a long period where Jade ward did not have psychology input. Jade ward also did not have a substantive OT to provide activities but only received support when needed from the wider trust OT team. This meant that patients had reduced access to psychology support and activities.

Staff on the wards were trained to carry out physical interventions. However, not all staff we spoke to felt confident to deal manage aggression on the wards when patients became distressed. For example, one staff member told us they did not always feel safe on the wards. One staff member told us some staff members, even though trained in PMVA, did not feel confident and competent to apply the PMVA knowledge so they did not feel safe on the ward when working with such staff members. We found the PMVA compliance rate for Jade and Maple wars to be 86% and 90% respectively.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency.

Staff had received and were up to date with most appropriate mandatory training. The training was appropriate for the patient group using the service. Overall training compliance for the wards ranged between 87% on Amber ward and 95% on Pavilion ward. However, for some training modules there was lower compliance, such as PMVA.

All ward areas were not always clean. We received mixed feedback about the cleanliness of the ward environment from patients, carers and staff. During our inspection, 6 patients on Maple ward and 3 patients on Pavilion ward told us that they felt the ward was unclean. We found Maple ward to be unclean with pieces of litter scattered on communal floor and the dining area. Staff told us toilets and bathrooms on the ward were dirty most of the time and that this was worse on weekends. One member of staff from Pavilion ward told us some housekeepers cleaned very well but others did not. Another staff member said the ward housekeeper also prepared food at mealtimes so did not have sufficient time to complete both tasks with diligence. For example, the cleaner served food during mealtimes and switched over to cleaning after meal was served. Staff believed the dual role impacted the housekeeper’s ability to clean the ward thoroughly.

Staff said they followed infection control policies, received infection prevention control training, and had appropriate protective personal equipment to keep themselves and patients safe. Staff followed hand hygiene guidelines and regularly completed hand hygiene audits.

Managers held regular cleaning and infection prevention control audits of the service to ensure processes were in place to maintain the cleanliness and infection control standards of the service. Staff followed infection control policies, including handwashing. Managers ensured staff received appropriate personal protective equipment. Most staff were up to date with infection control training with a compliance rate of 80% across the service.

The service had systems and processes in place to support the safe administration and recording of medicines. Medicines were prescribed and administered by trained staff, and controlled drugs were stored securely with accurate registers. Pharmacy teams worked closely with ward staff, attended multidisciplinary team meetings, and supported medicines reconciliation and audits. Consent to treatment documentation under the Mental Health Act was in place and aligned with prescribed treatment. Clozapine and lithium were monitored in line with national guidance, and physical health checks such as NEWS2 observations and ECGs were usually completed.

Staff did not always manage medicines safely and in line with best practice. We found gaps in ambient room and fridge temperature checks across multiple wards, which could lead to missed temperature excursions. On Amber ward, opened and expiry dates were not consistently recorded on liquid medicines, and on Rowan ward, patient-identifiable information was disposed of in general waste. Records for ‘when required’ (PRN) medicines were often incomplete; medicines were frequently administered at maximum doses without clear documentation of rationale, effectiveness, or alternative strategies attempted. We saw examples of PRN medicines being used for insomnia without appropriate justification. Post-dose monitoring following Rapid Tranquilisation (use of medication by intramuscular injection where urgent sedation with medication is needed) was incomplete in 3 records we reviewed at Maple, Palmeira and Falmer wards, and most uses of PRN antianxiety medicine lacked documentation of why the medicine was used, what de-escalation was attempted, or whether it was effective. Blood glucose (BG) machine quality control checks were inconsistently recorded, and for one patient, a patient’s insulin was not administered on four occasions when their BG readings exceeded the threshold set out in their care plan. For another patient prescribed high-dose antipsychotic therapy, none of the required HDAT monitoring was in place. Stool chart monitoring for clozapine patients was usually completed, but for one patient on Falmer ward, no records were present despite known risks.

We were concerned about the process of medicines administration on Amber ward. The door to the clinic room was left open, therefore staff did not have protected time to administer medicines. We found patients and staff walking in to speak to the staff while they administered medicines. This concern was fed back to the team.