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

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

At the last assessment, this key question was rated requires improvement. At this assessment, the rating has improved to good.

This meant patients were safe and protected from avoidable harm.

At the last assessment, the provider was in breach of regulations relating to safe care and treatment (Regulation 12) and staffing (Regulation 18). During this assessment, we found improvements had been made in relation to staffing oversight, mandatory training compliance and physical health monitoring.Restrictive practice remained low, with 4 episodes of rapid tranquillisation in the previous 12 months, all oral and accepted, involving 1 patient.

Patients were supported safely by staff who understood their individual risks, communication needs and triggers. Staff used personalised behaviour support plans and adapted communication approaches to respond consistently to signs of distress or emotional need. Physical health oversight was robust and supported by weekly General Practitioner (GP) attendance. Infection Prevention and Control (IPC) Level 2 training compliance was 100%. Staff used daily multidisciplinary huddles and structured reviews to monitor risk, incidents and leave arrangements.

However, during the assessment we identified concerns relating to medicines storage and environmental oversight. We found a medicines cupboard left unsecured and routine monitoring for patients self-administering medicines was not always evidenced. We also observed damaged fencing and debris, including exposed wires, within the second garden area. Kitchen hygiene standards were not always maintained.

Following the assessment, the provider took action to address the concerns identified, including repairing fencing, removing debris, replacing the dishwasher and securing the medicines cupboard. However, governance and environmental oversight systems had not identified or resolved these concerns promptly prior to the assessment.

Staff promoted autonomy and positive risk-taking in line with the principles of Right Support, Right Care, Right Culture.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence showed a good standard. The service had a proactive and positive culture of safety based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to identify and embed good practice.

In the 12 months prior to the assessment, 95 incidents had been reported, the majority categorised as low harm. Restrictive practice remained low, with 9 episodes of rapid tranquillisation recorded, all oral and accepted, involving 1 patient. Staff used safety crosses to monitor incidents and safety concerns in real time. These were updated daily and were all green on the day of the assessment, indicating no recent incidents or identified safety concerns.

Staff understood the importance of incident reporting and described how incidents and restrictive interventions were reviewed through reflective practice, multidisciplinary discussions and safety reviews. Staff told us learning from incidents was used to update support plans and inform care delivery where required.

The service had recently delivered refresher training relating to ligature risks. Staff described how learning from incidents and environmental risks informed safety improvements within the ward.

Staff understood the duty of candour and described being open and transparent with patients and families when incidents occurred. Staff also told us they received support and opportunities for reflection following incidents and challenging situations.

Staff demonstrated a positive approach to learning, reflection and improving safety practices.

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

The service had clear referral and admission processes to ensure patients’ needs could be safely met within the service. Staff worked collaboratively with commissioners, community teams and external providers to support continuity of care and safe transitions into the community. During the assessment, we observed a referrals multidisciplinary team meeting where staff discussed patients respectfully and agreed clear next steps relating to transitions and discharge planning. There were clear systems in place to review and manage risk. Staff held daily multidisciplinary huddles to review incidents, risks and changes in patients’ presentation from the previous 24 hours and agree immediate actions, including reviewing or temporarily suspending Section 17 leave where required. Ward rounds reviewed leave arrangements, patterns of risk and progress towards discharge. Six-monthly reviews brought together structured risk assessments, psychological formulation and progress.

During the assessment, we observed a referrals multidisciplinary team (MDT) meeting involving 3 wards where staff discussed patients respectfully and agreed clear next steps relating to transitions and discharge planning. Staff involved relevant health and social care professionals to support continuity of care within the service and following discharge.

Pharmacy input to the ward was effective, and records relating to post-rapid tranquillisation monitoring and missed doses were clear. Staff also worked proactively with external agencies and community providers to support patients preparing for discharge, including sharing “risk on a page” summaries and providing transition support where required.

However, routine monitoring for patients self-administering medicines was not always evidenced, which reduced assurance that medicines systems were consistently monitored.

The Quality of Life Tool supported these findings and showed staff understood their roles in delivering safe, consistent and person-centred support.

The evidence showed a good standard. The service worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve this. Staff focused on improving patients’ lives while protecting their right to live safely and free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared safeguarding concerns appropriately.

Safeguarding concerns were identified and managed appropriately. In the 12 months prior to the assessment, 8 safeguarding concerns had been recorded. These included patient-on-patient emotional and physical incidents, a staff-related financial concern and incidents involving threats or intimidation. Actions taken were timely and proportionate. All safeguarding concerns had been closed by the local authority, with 2 upheld. Police involvement was sought where appropriate.

Staff were trained in safeguarding, knew how to raise safeguarding concerns and were aware of the safeguarding lead within the service. Staff understood how to identify adults at risk of harm and demonstrated an understanding of patients’ individual risks, communication needs and vulnerabilities. Staff worked collaboratively with external agencies where safeguarding concerns had been identified.

Patients told us they had regular access to Independent Mental Health Advocate (IMHA) support. Staff demonstrated an understanding of equality, diversity and communication needs when supporting patients, including patients with learning disabilities and autistic patients. Staff used personalised communication approaches and adapted support plans to help patients understand risks, restrictions and safeguarding processes.

Restrictive practice remained low within the service. There were 5 incidents of physical restraint and 4 episodes of rapid tranquilisation in the previous 12 months all involving 1 patient. There were no incidents of prone restraint, seclusion or long-term segregation. Staff described how restrictive interventions were reviewed following incidents to identify learning and ensure support plans remained appropriate and least restrictive approaches.

The Quality of Life Tool supported these findings and showed staff understood patients’ communication needs and used personalised approaches to support patients safely while promoting autonomy and independence.

Mental Capacity Act

Staff had a good understanding of the Mental Capacity Act, particularly the five statutory principles. Mental Capacity Act training compliance was 100%. Mental Capacity Assessment Recording and Consent to Treatment training compliance was also 100%. Mental Health Act training compliance was 100%.

The provider had a policy relating to the Mental Capacity Act, and staff knew where to seek advice and support regarding capacity and consent issues. Staff supported patients to make decisions wherever possible and used accessible communication approaches tailored to patients’ individual needs. These included symbols, photographs, plain language and personalised visual communication tools for patients with learning disabilities and autistic patients.

For patients who may have impaired mental capacity, staff assessed and recorded capacity appropriately in relation to significant decisions. Where patients lacked capacity, staff considered patients’ wishes, feelings, culture and preferences when making best interest decisions. Patients had access to Independent Mental Health Advocate (IMHA) support where appropriate.

Records reviewed during the assessment showed staff considered consent, communication needs and patients’ involvement in care planning and decision-making processes. Staff shared information with families and carers only with the patient’s consent.

The service had systems in place to monitor adherence to the Mental Capacity Act through care record reviews, multidisciplinary oversight and governance processes.

The evidence showed a good standard. The service worked with patients to understand and manage risks by thinking holistically. They provided care that was safe, supportive and enabled patients to do the things that mattered to them.

We reviewed care plans and risk management documentation during the assessment. Patients were involved in understanding and managing their own risks and received copies of key documents, including care plans and risk management plans. Staff shared information with families and carers only with the patient’s consent.

Restrictive practice remained low within the service. In the 12 months prior to the assessment there had been 4 episodes of rapid tranquillisation, all oral and accepted, involving 1 patient. There was no use of prone restraint, seclusion or long-term segregation during the assessment period. Staff described how restrictive interventions were reviewed following incidents to identify learning and ensure support plans remained appropriate and least restrictive.

Relapse prevention plans were co-produced with patients. Decisions relating to leave and risk management were discussed in ward rounds and daily multidisciplinary huddles, so patients understood the rationale for decisions and any changes to restrictions or support arrangements.

Staff communicated with patients in ways they could understand and used personalised communication approaches to support patients with learning disabilities and autistic patients to participate in decisions about their care, treatment and risk management. Accessible support plans using symbols, photographs and plain language were available where appropriate.

Psychology staff developed “risk on a page” summaries and provided training and transition support to community providers as patients prepared for discharge. Patients were also supported to provide feedback through community meetings and discussions relating to activities, routines and care planning.

Patients had access to Independent Mental Health Advocate (IMHA) support where appropriate. The Quality of Life Tool supported these findings and showed staff promoted positive risk-taking, choice, control and independence while supporting patients safely.

The evidence showed some shortfalls. The service did not always detect and control potential risks within the care environment. They did not always ensure equipment, facilities and the environment supported the delivery of safe care.

During the assessment we observed damaged fencing and debris within the second garden area, including broken plastic and exposed wires. This area was accessed under staff supervision. We also observed stained and dirty drawers within the kitchen area and found the ward dishwasher was broken. In addition, we identified a medicines cupboard left unsecured during the assessment, which did not support safe medicines storage arrangements.

These concerns had not been identified or resolved promptly through the service’s environmental oversight and governance processes. This created a risk that patients could be exposed to avoidable harm.

Following the assessment, the provider took action to address the concerns identified, including repairing fencing, removing debris, replacing the dishwasher and securing the medicines cupboard. The provider told us this was not reflective of usual ward practice and pharmacy audit results demonstrated consistent compliance with expected standards. Staff had been reminded of the need to remain vigilant during medicines checks and to adhere to established safety procedures.

The Quality of Life Tool is an observational tool assessment used to evaluate how well ward environments promote independence, wellbeing, choice and quality of life for patients. The Quality of Life Tool highlighted that although many areas of the environment were appealing and supported independence, sensory needs and homeliness were not always consistently considered across all areas of the ward environment.

However, the ward environment was generally clean and well maintained, with en-suite bedrooms and communal areas available for patients to use. Staff completed environmental risk assessments and patients had access to nurse call systems and staff alarms. The ward complied with guidance relating to mixed-sex accommodation.

The first garden area had been co-designed with patients and was accessible during the day using fob access, which promoted independence and autonomy.

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. Staff worked together to provide safe care that met patients’ individual needs.

The service had enough nursing and support staff to support patients safely. Staffing levels and skill mix supported the delivery of safe care and rehabilitation-focused support. The provider told us the staffing establishment included 12 permanent nurses, 6 of whom were learning disability nurses. There were usually 2 learning disability nurses on each shift to support patients’ individual communication and care needs and managers adjusted staffing levels according to patients needs.

Over the 12-month period from February 2025 to January 2026, staffing stability at Brookfield Centre had improved. Vacancy rates reduced from 14.4% in February 2025 to 5.4% by January 2026. Staff turnover also reduced during this period, falling from 13% in February 2025 to 0% between November 2025 and January 2026. Sickness absence remained at a manageable level throughout the reporting period.

The service was not using agency staff. Bank shifts were primarily covered by substantive staff working additional hours, which promoted continuity of care and consistency for patients. Staff told us they knew the patients well and understood their risks, routines and support needs.

Managers adjusted staffing levels daily according to patients’ needs. Staffing levels allowed patients to access activities, escorted leave and one-to-one support. Staff told us multidisciplinary working within the ward was positive and supportive.

Staff told us they felt supported by the ward manager and described a positive and reflective team culture. Staff said they felt able to raise concerns and described opportunities for reflective practice and learning following incidents and challenging situations.

Staff had completed and kept up to date with mandatory training. Immediate Life Support and Physical Intervention training compliance were both 100%. Staff told us training was relevant to the patient group and supported them to meet patients’ individual communication, behavioural and physical health needs safely.

There were enough staff on shift to carry out physical interventions safely when required. Staff shared key information through daily handovers, multidisciplinary huddles and ward rounds to help keep patients safe.

The evidence showed some shortfalls. The service did not always ensure infection prevention and control risks were identified and addressed promptly.

During the assessment we observed some kitchen hygiene concerns, including stained drawers and a broken dishwasher. These issues had not been addressed promptly prior to the assessment.

Following the assessment, the provider took action to address the concerns identified, including replacing the dishwasher and addressing the cleanliness concerns within the kitchen area.

Although systems were in place to support infection prevention and control, oversight processes had not always ensured environmental hygiene concerns were identified and resolved promptly.

However, Infection Prevention and Control (IPC) Level 2 training compliance was 100%. Staff adhered to infection prevention and control principles, including handwashing, and staff completed regular cleaning and environmental checks within the ward environment.

The ward environment was generally clean and well maintained. Cleaning records were up to date and demonstrated that ward areas were cleaned regularly. Staff maintained equipment appropriately and risks relating to infection prevention and control and pest control were recorded on the service risk register for monitoring and oversight.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. Staff followed the principles of STOMP (stopping over medication of people with a learning disability, autism, or both with psychotropic medicines).

During the assessment, the medicines inspector reviewed 7 electronic prescribing and medicines administration (EPMA) records and patient records, spoke with 6 staff including nursing staff, medical staff, pharmacists and the ward manager, and reviewed medicines policies, audits and the clinic room.

The service had systems and processes in place to support the safe and effective use of medicines. Staff followed clear protocols for prescribing, storing and administering medicines and made effective use of the electronic prescribing and medicines administration (EPMA) system to prescribe and record medicines administered accurately. Medicines, including controlled drugs, were stored securely and emergency equipment was routinely checked and maintained. Staff completed medicines reconciliations on admission and had access to records that supported this.

Medicines were supplied during working hours and staff were able to obtain medicines and advice out of hours when required. A clinical pharmacist attended ward rounds and provided expert advice on medicines optimisation and the safe use of medicines. Patients also had opportunities to speak with the pharmacy team about their medicines during regular drop-in clinics. The pharmacy team supported prescribers to review and reduce medicines where appropriate in line with STOMP principles.

Staff regularly reviewed and monitored the impact of medicines on patients’ health, including monitoring side effects and managing associated risks. Staff were aware of the physical health risks associated with certain medicines. For example, patients prescribed clozapine received daily monitoring of bowel movements. Staff also completed regular side-effect assessments for patients prescribed antipsychotic medicines using nationally recognised rating scales.

Physical health information was accessible through patients’ electronic care records, which supported timely clinical decision-making and the delivery of safe care. Care plans were in place to support patients with long-term physical health conditions and medicines-related health needs.

The use of ‘when required’ (PRN) medicines for agitation and aggression was low. Staff prioritised de-escalation and used behavioural support plans developed with patient involvement to reduce the use of PRN medicines. Where oral PRN medicines were used, staff documented the rationale and outcomes within patient records. Rapid tranquillisation via intramuscular injection was rarely used within the service, and staff were able to describe the processes required to support its safe use.

The service had a stepped programme to support patients to self-administer medicines where this was safe and appropriate. Risk assessments were completed before patients began the process. Patients had lockable medicines cabinets within their bedrooms to support independence in managing their medicines.

Patients detained under the Mental Health Act had appropriate legal authority in place for medicines administration. Consent forms were available electronically and staff checked legal authorisation before administering medicines. During the assessment, we identified 1 consent form which did not include authorisation for high-dose antipsychotic treatment. Staff addressed this immediately.

The pharmacy team completed audits and shared learning with ward teams. Medicines incidents were reviewed and acted on where trends or themes were identified. Staff received regular medicines training and the service had systems in place to ensure staff were aware of medicines safety alerts and incidents.