Kent and Medway Mental Health NHS 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

At our last assessment, we rated this key question as inadequate. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and although systems were improving there was limited assurance about safety. Whilst the trust had made improvements to the physical health monitoring of patients and new processes had been put in place to improve the safety of the service, there was a continuing risk that patients could be harmed as there was an inconsistent approach to assessing and monitoring risk using the new systems. This was because they were not yet fully implemented. As a result of this we found the service to be in breach of regulation 12 (safe care and treatment).

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

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 people’s safety.

We reviewed 16 sets of care plans and risk assessments across the locations. Since our last inspection, 2 out of the 3 sites waiting lists were being managed more effectively. We saw evidence of patient tracking list meetings and waiting list reviews that resulted in escalation of urgent cases. However, at South Kent Coastal team we reviewed 5 sets of care and treatment records. Four out of 5 records we reviewed did not have future appointments booked as per the MHT+ guidance. In Kent and Medway NHS services, Mental Health Together (MHT) and Mental Health Together+ (MHT+) provide community-based mental health support, with MHT handling primary care and MHT+ focusing on complex, specialist, or older adult care. MHT covers mild-to-moderate needs, while MHT+ is for specialised interventions. Although future appointments were not being documented in the care records, we could see that this was being identified and flagged by an internal system called “Power BI” which was being reviewed in practice by a dedicated member of staff during the handover and addressed by the teams. This meant that although there was a process to contact service users while they were waiting to access care and treatment patients were still occasionally not being contacted whilst waiting, which could place them at risk of harm as the process was not yet fully implemented.

Overall, waiting list management had improved, supported by patient‑tracking meetings and regular reviews that enabled the escalation of urgent cases. The majority of people waiting for interventions in Mental Health Together (MHT) and Mental Health Together Plus (MHT+) were waiting within 120 days (17.1 weeks). A considerable proportion of patients in both services were waiting within 59 days (8.4 weeks). Patients were provided with information about available support while waiting for services, including voluntary sector and emergency options.

Whilst the trust had introduced a new process for risk assessment and management called the CRAM (clinical risk assessment and management), the system was not being used consistently. It was still in the process of being rolled out, across all services. Staff were all aware of the CRAM due to recent training, but this was still a work in progress and the staff in the services told us that they felt the training for CRAM had been rolled out quickly without enough time to embed the learning. Staff at all levels told us they were aware of issues with inconsistency in the care records.

Weekly multidisciplinary team meetings included agenda items that enabled oversight of patient’s care and treatment needs. Discussions covered areas such as waiting lists, patients currently receiving inpatient care, and complex cases. Meetings were attended by staff from other specialist teams. These meetings enabled direct discussion of patient’s needs, the sharing of specialist advice, and joint care planning.

We observed effective team and multidisciplinary meetings. An occupational therapy allocation meeting showed a high level of understanding of patients’ needs and risks. Multidisciplinary meetings we observed were well attended by all disciplines, both within and outside the community team that hosted the meeting. Discussions were thorough and showed an effective team approach to support patients care that included discussions about waiting lists, discharges, new assessments and risks.

Risk issues were being captured in the contemporaneous notes in detail, but it was time consuming to access. Although this was against trust policy, staff were able to do this competently and knew where information would be stored as the process for managing patient care and treatment records had been improved since the last inspection.

Progress notes were thorough and the care records were easily navigated by the staff when they were showing us how they used the electronic system. It was also evident through conversations with staff and observations of care records, that staff had a good knowledge of the patients they cared for and understood their risks. However, since the last inspection navigation of care records remained a time consuming process and relied on the competence and experience of the individual staff members. Risk events were being recorded in the progress notes but not in the event log, which meant that staff were required to review pages of progress notes. This meant that opportunities to take action to prevent incidents re-occurring could be missed.

In the March 2025 inspection, we identified that physical health or compliance checks of patients prescribed regular oral mental health medicines were not always up to date. The trust now carried out regular clinical audit of physical health monitoring. The results were now shared in a clearer way so teams could see the percentage compliance for cardiometabolic checks. Cardiometabolic checks are critical for patients supported by community mental health services because individuals with serious mental illness are at significantly higher risk of preventable physical illness and premature death. The physical health team sent the physical health monitoring information weekly to clinical leads, so teams could identify where checks were being missed and follow this up.

Regular meetings were held to review the data in relation to the running of the service and to act on any concerns identified. Clinical Nurse Leads (CNLs) in MHT+ and matrons had a weekly catch‑up every Monday to review the physical health information that had been circulated and agree what needed to improve. Where compliance was low, the trust provided targeted physical health workshops to support those locations and address the issues affecting completion. Senior oversight was in place as the Head of Nursing and matrons also reviewed the physical health data every Monday to monitor compliance and respond to any areas of concern.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We scored the service as 1. The evidence showed significant 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 16 sets of care plans and risk assessments across the locations.

The adult community mental health service continued to demonstrate an inconsistent approach to assessing and monitoring risk. Although progress notes were generally detailed and medical letters were comprehensive, some care records lacked up‑to‑date and robust care plans, dialogue+, risk assessments, risk management plans, crisis plans, and discharge plans in the new CRAM format. The inconsistent approach to assessing and monitoring risk meant that some patients using the adult community mental health services may not have had their current risks clearly identified, documented, or managed. There was an increased risk that patients would not receive timely, coordinated, or appropriate support in response to deteriorating mental health or changes in risk.

The absence of consistently completed Dialogue+ records and crisis plans may have limited patients’ opportunities to actively participate in planning their care and to understand what support would be available during a mental health crisis. This could reduce patients’ confidence in the service and increase the likelihood of avoidable harm, crisis escalation, or unplanned hospital admission.

We reviewed 16 care records in relation to risk assessments, 12 records contained risk assessments that were up to date, and broadly reflected patients identified risks. Four did not contain up‑to‑date or comprehensive risk assessments. Of these 4 records, one risk assessment was very brief, and did not include significant historical risks, one did not align with the risks recorded on the person’s care record alert, one did not reflect risks identified in the person’s assessment, and one was out of date. This meant that staff may be unclear about a person’s risks as it was not consistently recorded.

Of the 16 care records reviewed, 11 included current care plans. The trust confirmed that the 5 records without current care plans were reviewed and updated immediately during the inspection.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We scored the service as 2. The evidence showed some shortfalls. The service was midway through a staffing model change and did not always make sure there were enough qualified, skilled and experienced staff.

Since the previous inspection, staffing had improved across all locations, but all locations required further improvement to be fully staffed in all areas.

MHT+ focuses on complex, specialist, or older adult care. When we met with managers, we could see an initial review of the staffing model had been undertaken for MHT+. The staffing model review had been implemented at the Thanet location and at the time of the inspection was due to be reviewed in the Ashford and Canterbury and the South Kent Coast teams. The teams had conducted a red, amber, green audit which fed into the review of the staffing model and identified staffing gaps which were being addressed in each team. However, this piece of work was due to be completed In January 2026.

We observed the development of a caseload management tool which was utilised to identify risk factors and any changes.

The trust’s training policy set out expectations for the mandatory training of all staff and volunteers, including agency staff. Training compliance was generally high across all teams.

The trust had implemented a weekly care optimisation huddle where the location teams provide assurance to the Strategy Deployment Review (SDR) process that governance, clinical quality and safety related to patient flow, demand and capacity management are effective across the community teams. This meant that there was regular oversight to board level of the staffing and clinical quality.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.