Kent and Medway Mental Health NHS 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

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

At our last assessment we rated this key question Inadequate. At this assessment the rating has changed to Requires improvement. Some improvements had been made since our last comprehensive assessment in 2023 such as the auditing of emergency response equipment, enough nursing and support staff was deployed to the wards to keep patients safe and a new medicines record keeping system (EMPA) had been put in place across the trust.

However, some aspects of the service were not always safe and there was limited assurance about safety. We found the service to be in breach of Regulation 12, as staff were not ensuring that all incidents and near misses were appropriately reported and recorded. The trust did not always ensure that medicines used for the management of anxiety or agitation were always used and recorded appropriately. The service was also in breach of Regulation 13 as the trust did not ensure that staff were recording and regularly reviewing any restrictive interventions in place. The service was in breach of regulation 15 as the trust did not ensure that maintenance issues were rectified in a timely way. Some of the maintenance issues we identified had been raised a long time before our inspection and had still not been addressed. The system in place for recording and monitoring maintenance requests was ineffective.

This service scored 47 (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 a 1. The evidence showed significant shortfalls. Staff did not always report incidents in a timely way which affected the trust’s ability to learn lessons and prevent the incident from recurring. Patients and staff were not always included in debriefs after incidents had occurred.

There had been 11 incidents reported during the 12 months (16 September 2024 - 15 September 2025) prior to the inspection that required investigation in line with the Patient Safety Incident Response Framework (PSIRF). These either required a patient safety incident investigation (PSII), or an after action review. Of these, 5 were relating to suspected or actual suicide, 2 missing persons, 1 self harm incident resulting in moderate injury and 1 estates concern. The trust was also conducting a PSII and thematic review in relation to incidents of venous thromboembolism as there had been a number of incidents relating to this. At the time of the assessment, this review was underway.

At this assessment, we found that the reporting of incidents and near misses on the trust’s internal reporting system continued to be inconsistent. This was an area of improvement raised at the previous assessment. Although staff we spoke with told us they now understood what incidents to report and how to report them, staff did not always report all incidents that they should. For example, on Foxglove ward we found a medication error detailed in a patient's record that had not been reported, on Fern ward a suspected bed bug infestation had been discussed in handover but not formally reported and an issue with sewage which had not been appropriately reported. We raised these concerns with the staff, and they took immediate action to address the issues. On Chartwell ward, there were 3 incidents involving patients that were discussed in handover. Two out of the 3 incidents had not been reported. Following the inspection the trust told us that the third incident had occurred the previous day and was therefore still within the timeframe of 24 hours. The inconsistent approach to the reporting of incidents put patients at risk of avoidable harm because incidents had not been appropriately investigated and mitigations put in place preventing them from reoccurring.

When staff reported incidents, they were reviewed by senior leaders such as matrons daily and assigned to ward managers to action. We observed that recent and significant incidents were discussed in handovers. Managers and deputy ward managers told us that they received emails whenever any incident forms were submitted and that they would ensure appropriate action was taken, but they did not always have time to update the incident reporting system to reflect this.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong. Duty of candour was a required section to complete on incident forms.

Sharing of learning from events at ward level was inconsistent. On Foxglove ward, learning from events was distributed via emails and team days. We were not assured that staff always read these emails and we were not provided with evidence that learning was discussed regularly, such as during team meetings or in supervision meetings. However, on Chartwell ward and Cherrywood ward, we saw evidence that learning had been shared in the acute directorate governance meeting, which had input from the trust clinical governance team to disseminate learning more widely.

Staff were debriefed and received support after a serious incident. Staff told us they felt well supported following incidents and were given time off to recover if they had been physically injured. Psychology staff were involved in offering debriefs to staff after serious incidents and offered reflective practice to staff on all sites. However, some patients and staff reported that those who witnessed incidents were not always offered debriefs. Some staff felt that assaults led to staff burnout and increased staff sickness.

We scored the service as 3. The evidence showed a good standard. The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when patients moved between different services.

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 be safely met. The trust had a patient flow team who organised all admissions and discharges from the service. Patients always had a bed to return to if they needed an acute hospital admission during their stay. However, this was not always guaranteed to be the ward that they had been admitted to previously.

Staff involved all the necessary health and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. Named keyworkers were routinely invited to ward reviews and discharge planning meetings to ensure continuity of care for patients.

We scored the service as 1. The evidence showed significant shortfalls. The service had blanket restrictions in place on all wards. We identified that not all restrictions were recorded. Some patients were unable to access drinks and snacks without asking staff. However, the service worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving patients’ lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately. Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Staff kept up to date with their safeguarding training. Staff knew who their safeguarding leads were and who to go to for advice.

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

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies.

The electronic incident reporting system had a dedicated area for safeguarding, which allowed teams to keep track of referrals. Safeguarding was discussed in several forums, including a monthly safeguarding meeting which was attended by external partners such as Kent County Council and police liaison. There were no Section 42 enquiries currently active for the wards visited at the time of the assessment.

There were several blanket restrictions in place on all wards and the rationale and record keeping for the restrictive practice was not always clear and required improvement. The quality of the blanket restriction logs for each ward contained little detail and included no rationale or decision making. The log did not always reflect the current practice on the ward. For example, the Fern ward blanket restriction log stated that access to the garden was limited at only set times of the day. However, the manager told us that the garden was open at all times with zonal observations. Willow suite had restrictions on crisps, drinks, and fruit due to the risks posed by 1 patient. On 1 of the wards, daily rooms checks were being completed for 2 patients each day. This was to identify any contraband or risks in each person’s bedrooms. Items such as shoelaces and drawstrings were removed from the bedrooms and recorded on the log. We were told this had been put in place due to an incident that had occurred 2 months ago. There was no evidence that these restrictions were being closely monitored.

The lack of routine monitoring and oversight of blanket restrictions meant that restrictions were not being regularly reviewed to ensure they were the least restrictive or to reduce them. Following our inspection, the trust had implemented a new standardised blanket restriction log so that the recording of restrictions was consistent across all wards. The trust told us that the quality assurance system had been recently changed, and service leaders were expected to present a monthly quality of care overview which included all blanket restrictions in place.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 29 patient records during the assessment.

Between 1 September 2024 and 31 August 2025, acute and PICU wards had 629 incidences of restraint, of which 66 were in the prone position. Many of these restraints (266), were attributable to 26 patients on the ward, 2 of whom had high risk of self-harm and harm to others during their admission. The service had 122 occasions of oral rapid tranquilisation and 293 occasions of intramuscular rapid tranquilisation.

This period of reporting also showed 162 episodes of seclusion, with the most being attributable to the PICU ward. During the same reporting period, 8 occasions of long-term segregation occurred. Littlebrook Hospital infrequently used the seclusion room/extra care area of the hospital for the acute wards.

Staff did not consistently ensure that patient risk assessments were updated following an incident. At Littlebrook Hospital and Priority House, interventions were not always being reviewed and updated following incidents. For example, we identified in 2 patient records that they had been involved in a recent incident, but the incident had not been reflected in the patient’s risk assessment. We were not assured that staff identified and responded to changes in risks and therefore were unable to mitigate them.

Staff enabled patients to give feedback on the service they received such as during community meetings and at a monthly virtual patient forum. Whilst staff followed trust policies and procedures when they needed to search patients or their bedrooms to keep them safe from harm, the rationale for why some restrictive interventions were taking place were not always clear and documented. For example, staff on Cherrywood ward were searching 2 patient bedrooms every day and removing items that could be used for self-harm such as shoelaces and jumper cords although the level of intervention did not correlate with the patient’s risk levels. Following our inspection, the trust told us that an enhanced room search process was implemented following a patient safety incident a few months prior to our inspection and the room search process was time limited.

Staff ensured that patients could access advocacy.

Staff completed therapeutic observations as prescribed. We found no gaps in documentation and observations were randomly completed for those on enhanced observations. This required staff to randomly check on a patient four times within an hour. Staff were also allocated to carry out observations for no more than an hour at a time. General observations were also completed with no concerns although staff were not always following the guidance stated on the forms.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always ensure that staff were aware of potential risks in the care environment and how to mitigate these. They did not always ensure that maintenance requests were acted on in a timely way and had no consistent way of monitoring maintenance and estates requests. They did not always make sure equipment, facilities and technology supported the delivery of safe care. Although staff carried out regular risk assessments of the care environment including ligature risk assessments, ward staff on Upnor and Fern ward were unaware of the ligature risk assessment in place and were unsure about what the document was or where to find it. We were not assured that staff understood where the potential ligature anchor points were and mitigated the risks to keep patients safe. This meant that patients were at risk of avoidable harm.

Not all wards were completing daily environmental checks to ensure safety concerns were being recorded and action taken to address these. Records showed that staff were meant to complete these twice a day. However, Upnor ward and Cherrywood ward had limited records to show that this was taking place. There was an increased risk of environmental safety concerns being missed by staff.

Wards had ligatures cutters and scissors in place and staff knew where these were located.

Staff could observe patients in all parts of the wards. The wards were using zonal observations to observe all parts of the wards. Staff were positive about this and felt they were able to manage risk as a result.

The ward complied with guidance on eliminating mixed-sex accommodation.

Staff had easy access to alarms and patients had easy access to nurse call systems. These were checked weekly to ensure they worked. The Trust had recently initiated random emergency simulations to determine how long it took staff to respond to an incident on the ward. This was monitored trust wide.

At the time of our September 2025 assessment, we identified that the overall management and oversight of maintenance and estates issues needed improvement. Whilst staff told us that there had been an improvement in the responses to estate requests, we found a variety of estates concerns across all locations that that had been raised a long time before our assessment but had still not been addressed. Wards were inconsistent in their management and monitoring of estates concerns.

For example, the hot water dispenser on most wards were either not present or broken. Some wards were using hot water flasks and others required staff to make hot drinks for patients. We were told this was a temporary measure until purpose built taps could be installed on the wards in the coming months. On Foxglove ward, door top sensors for the quiet room had been on the ward risk register since 2012 and at the time of inspection these were still not in place. On Willow suite, while the ward manager told us that maintenance concerns were addressed quickly, we observed broken televisions with no estimate for when these would be replaced and broken TV cabinets which were due in December. The ward had to wait a year before the sink and taps in the patient lounge area was replaced. Following our inspection, the trust told us that the delay had been caused by the need to procure a specialist anti-ligature tap. There were significant delays in replacing bedroom door locks and weight bearing alarms which were due to be replaced July 2025 but had been delayed to October 2025. The delay in estates and maintenance repairs had a negative impact on the patient environment and their overall experience. The trust told us that they had changed the contractors they worked with and were working with specialist contractors going forward.

All ward areas were clean and had good furnishings. However, Foxglove ward, Fern ward and Willow suite looked tired. The noticeboards on Foxglove ward had been removed due to damage, and they were awaiting a new style to be delivered. Staff told us that Fern ward was imminently being decorated, and they were involving patients in choosing the colour scheme for the ward.

We observed the environment of Willow suite to be untherapeutic. We observed the constant banging of doors and a lack of soundproofing on the ward. The ward manager had tried to take action to mitigate the effects of the environment by ordering noise cancelling headphones. The trust had also identified that there were issues with the estates provision for neurodivergent patients and were working with local commissioners to find a solution to this.

All of the seclusion rooms we visited during our inspection required further improvements. The seclusion room at Priority House had a strong smell, wooden batons holding back the wall and a viewing panel looking straight into the office of the 136 service. There were no blinds for privacy. We raised these issues with the Trust and were assured that action was taken to address these issues. At Littlebrook Hospital, the PICU seclusion room had no active camera in place for the continuous monitoring of patients using the area. We raised this with the trust, and they took immediate action to address the concern raised. We also found issues with the environment of the extra care area at Littlebrook hospital. The shower boarding was broken and crumbling, the sealant on the right side of the toilet was peeling away and the floor had degraded and could be lifted with force applied. We raised this with staff at the time of the assessment.

Although clinic rooms were fully equipped with accessible resuscitation equipment and staff regularly checked emergency drugs, staff were not consistently recording when some clinic room temperatures went above the recommended range and what actions were taken to reduce the risk of medicines degrading. Despite the clinic rooms being air conditioned to avoid overheating in summer, we identified several instances of clinic room temperatures being above the recommended temperature and no remedial actions were documented on the temperature monitoring form. Following the inspection the Trust told us that it would implement an automated temperature monitoring system, which would further strengthen assurance around medicines storage and provide real-time oversight of any temperature deviations.

For example, Chartwell ward had a prolonged period of out of range temperatures during August with no recorded action taken to rectify the errors in temperature. Upnor ward had some out of range temperatures where the thermometer was reset but no further action was recorded. Willow suite had two dates in August 2025 where the temperature reached 27c, however action stated “N/A”. We raised this during the assessment and after the onsite inspection the trust pharmacy team provided evidence that action was taken by reducing the expiry dates on the medicines affected. The lack of recording meant that trust leaders could not be assured that staff took appropriate action to mitigate any associated risks. There was also no formal record for staff to refer back to at a later date.

The trust gave assurances that an automated temperature monitoring system was due to be rolled out in the coming months. This would provide real-time oversight of any temperature deviations. The temperature checks of all clinic rooms were audited monthly.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met patients’ individual needs.

The service had enough nursing and support staff to keep patients safe. However, some staff told us that having many bank staff on shift led to inexperience on the ward and a lack of understanding about patient’s care. Wards being short of staff was a consistent theme of the inspection from staff, patients and families and carers. Staff told us that occupational therapy staff were supportive and could put on activities to help support when the wards were short of nursing staff. Staff told us that matrons and clinical leads were supportive.

The service had low vacancy rates. In August 2025 the vacancy rate for the assessment group was at 13%.

Managers limited their use of agency staff and requested staff familiar with the service from Bank, NHSP (NHS professionals is a service provides flexible staff bank for NHS organisations) or other wards. Managers made sure all bank and agency staff had a full induction and understood the service before starting their shift.

The service had low turnover rates. For the 12 months prior to the assessment, September 2024 to end of August 2025, the wards had a turnover rate of 13% (30 staff full time equivalent (FTE) leavers) but had recruited 65.8 FTE staff. Staff told us that turnover within the acute wards was considerable.

Levels of sickness were low. Managers supported staff who needed time off for ill health.

Managers accurately calculated and reviewed the number and grade of nurses, nursing assistants and healthcare assistants for each shift. The ward manager could adjust staffing levels according to the needs of the patients. Nursing staff and therapies staff told us that the wards are never fully staffed.

Patients had regular one to one sessions with their named nurse which were reflected within the care records. However, feedback from some patients was that they did not know who their named nurse was and they felt 1:1 care was lacking. Ward managers completed weekly audits of 1:1 sessions. This also ensured that care plans and risk assessments had been completed.

Patients section 17 leave was rarely cancelled, however staff reported that it was sometimes cut short due to staffing levels therefore patients weren’t always receiving their full amount of care planned leave. Some occupational therapies staff told us that they were required to support with escorted leave due to the wards being short staffed.

The service had enough staff on each shift to carry out any physical interventions safely. Wards could request support from other wards when needed.

Staff shared key information to keep patients safe when handing over their care to others.

The service had enough daytime and night time medical cover and a doctor available to go to the ward quickly in an emergency. Managers could call locums when they needed additional medical cover. Managers made sure all locum staff had a full induction and understood the service before starting their shift.

Most staff had completed and kept up-to-date with their mandatory training. The mandatory training programme was comprehensive. Managers monitored mandatory training and alerted staff when they needed to update their training. However, the trust had identified that their training does not meet the needs of patients and staff regarding the care of autistic patients. The trust was in the process of improving the training offer for their staff.

Most staff were trained in how to manage emergency life-saving situations. Non-qualified staff received training in basic life support (this was a 2-part training including theory and practical components). The completion rate for this training fell below the target for the trust with 87% of staff completing the practical training and 86% of staff completing the theory. Qualified nursing staff completed immediate life support training which 92% of required staff had completed. However, completion rates on Cherrywood ward, Amberwood Ward and Pinewood Ward fell below the trust target. We were assured by the trust that all staff who had not completed the training were booked on in the coming months.

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 maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly.

Staff adhered to infection control principles, including handwashing. Staff conducted audits to ensure their compliance with infection prevention and control.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always make sure that medicines and treatments were safe and met patient’s needs, capacities and preferences. The service did not ensure that staff knew where to find the most current consent to treatment forms. The service did not always ensure that medicines were used safely or in line with national guidance. Although staff followed systems and processes to prescribe and administer medicines using an electronic prescribing and medicines administration (EPMA) system, there were some concerns around documentation, monitoring, and oversight of high-risk medicines. Following the inspection the trust told us that they had taken immediate action to address the medicines concerns that were raised.

Pharmacists visited the wards daily and attended ward rounds regularly to ensure medicines use was optimised by providing expert advice to staff and patients. Pharmacy staff conducted weekly drop-in clinics for patients to help educate them about their medicines. Patients could access medicine information via QR codes, and medicines reconciliation was completed on admission. Pharmacist interventions were documented in patient records, and out-of-hours advice was available via an on-call pharmacist.

Whilst medicines were reviewed regularly, and the EPMA system in place allowed for review dates to be set with prompts from trust pharmacists, documentation for PRN medicines used for the management of anxiety or agitation was inconsistent. Patient records did not always explain the rationale for administration, what de-escalation techniques had been attempted, or whether the medicine had been effective.

This was identified across multiple wards. There was an increased risk that medication could be used inappropriately or increase patients’ risk of side effects. Following our inspection, the trust had implemented an action plan to strengthen compliance and oversight of when PRN medications are used.

Side effects of medicines were reviewed regularly using recognised rating scales. Patients on high-risk medicines, such as clozapine, were routinely asked about their bowel habits during multidisciplinary team reviews. However, we found gaps in bowel habit documentation. For example, in 3 care records we found inconsistent record keeping on the patients stool chart.

Staff had access to blood results and investigations to ensure medicines were used safely. Patients at risk of developing blood clots had venous thromboembolism (VTE) risk assessments completed. Patients prescribed high-dose antipsychotic treatment (HDAT) were flagged on the EPMA system, and physical health monitoring was in line with national guidance. In one case, HDAT was reviewed by the team and reduced due to non-compliance with physical health monitoring.

Despite the trust having policies and procedures and a new medicines record keeping system (EMPA) in place, post-dose physical health monitoring following rapid tranquilisation (RT) via intramuscular (IM) injection was not consistently completed in line with local or national policy. We found examples of missing or delayed observations, including incomplete NEWS2 charts and absent respiratory rate recordings, which may limit the ability to detect deterioration following RT. We also identified 2 incidents where doses exceeded national guidance. These were escalated to the service, which reviewed the events and implemented learning to prevent recurrence.

In addition to this, we identified several instances where Mental Health Act (MHA) consent to treatment forms were available electronically on the EPMA system did not match the medicines that patients had been prescribed. For example, we found that a person had been prescribed 4 medicines which were not included on the persons consent to treatment forms. We found similar issues for 3 other patients. The trust told us that consent to treatment forms were stored on the EPMA system. However, staff were relying on the physical consent to treatment files on the ward and the staff we spoke with did not know where they would be stored on the EPMA system. The lack of staff understanding on how to use the EPMA system increased the risk of patients being given incorrect medicines.