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

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

Key Question Score: 12 (38%)

Key Question Rating: Inadequate

At our last inspection we rated safe as requires improvement. At this inspection the rating has changed to inadequate. We identified 3 breaches of the legal regulations in relation to care and treatment, buildings, and premises and staffing.

Inadequate: Some aspects of the adult community mental health services were not always safe and there was limited assurance about safety. The service had high demand, insufficient staffing capacity, and had removed processes to proactively monitor risk to people who were waiting for assessments, treatment interventions, or medication reviews. This led to increased risk of people’s mental health deteriorating without the service’s knowledge, therefore increasing their risk of avoidable harm. As in our previous inspection in 2020, the service still did not always make sure people could access timely care and treatment. The service did not always monitor people’s physical health in line with National Institute for Health and Care Excellence (NICE) guidelines and the trust’s Antipsychotic Guidelines when they were on antipsychotic medication. Some of the service’s premises were not well maintained and did not provide therapeutic environments for care and treatment, with some rooms in a state of disrepair and others unable to be accessed at all. The internet was not reliable in all premises, which affected staff’s ability to carry out their work. The service had not yet improved its risk evaluation and decision process for responding to risk, and there were still inconsistencies across teams in how they applied the service’s risk evaluation and decision process for reviewing the risk of people who used services. People who were under the care of Mental Health Together (MHT) had longer waiting times and staff told us their processes meant they had less of an overview of risk within that cohort, than people who were under the care of Mental Health Together Plus (MHT+) or the early intervention in psychosis (EIP) services.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. Lessons were learned to continually identify and embed good practices.

The trust had implemented the Patient Safety and Incident Response Framework (PSIRF), which outlined how NHS organisations should respond to patient safety incidents for the purposes of learning and improvement. Staff received mandatory training on patient safety. The staff and leaders we spoke to showed a willingness to learn from incidents and complaints to improve the quality of services they provided to people who used services. Staff we spoke to were aware of how to raise concerns and how to report any incidents on the trust’s incident reporting software. Data showed that most incidents were reported the same day they occurred.

Staff could provide examples of learning from incidents, such as improving access to computer systems for partner providers so they could access important information to provide safe care. Learning from incidents was shared in multiple ways with staff at all levels to ensure learning happened across the service. Regular team meetings included learning from safety incidents and complaints. The minutes from these meetings were uploaded to shared drives and in some teams, they were also shared via email. We observed learning from incidents being discussed within team business meetings so that all staff could receive learning.

Staff told us that immediate debriefs (to support staff and identify any immediate learning and ensure everyone was ok) took place after incidents and were able to provide examples of this. Rapid reviews (an initial fact-finding exercise) took place to learn from incidents and share learning. Leaders at all service locations were aware of the themes of recent complaints and ongoing resolutions.

Over the previous 12 months, the total number of serious incidents for community mental health and crisis services, which covered working age adults and older adults, was 22. We saw evidence of thorough investigations into serious incidents that contained clear action plans for making improvements based on learning from the investigations. The service consistently applied duty of candour following incidents by providing both verbal and written explanations and apologies to people who used services and their families. Duty of candour is a provider’s responsibility to be open and honest when something goes wrong. The service monitored duty of candour and highlighted when records did not provide evidence of the process being followed, so it could be followed up. Learning from incidents within the service was shared across the trust. For example, there was a plan to hold a trust-wide learning event to raise awareness of domestic abuse and safeguarding concerns following an investigation into a suicide.

The trust encouraged trust-wide learning for all staff. Staff within the service were invited to attend the trust’s patient safety learning events and the service held “communities of practice” drop-in learning sessions, which brought learning together from across different specialisms within directorates.

The adult community mental health service had implemented the NHS Adult Community Mental Health Framework, which it called its community mental health transformation, in a staggered approach in 2024. The trust had decided to pause the roll out across EIP services, following staff feedback about concerns they had with the proposed changes, including the proposed removal of the physical health team. However, some staff across MHT and MHT+ said they felt that staff feedback about the transformation was not listened to and taken into consideration.

On the day the inspection team attended Coleman House, staff from the Improvement Team and a trust director were visiting as part of their series of listen and learn events. They told us they were looking at how the transformation was working from both a strategic overview as well as how the processes worked in practice. They held listen and learn events across the service.

People who used services did not always have timely access to treatment or medication reviews, and they were not monitored whilst waiting. This meant people’s mental health and wellbeing sometimes deteriorated whilst waiting for treatment, without the service knowing or being able to put appropriate plans in place.

At our last inspection in 2020, we found the service did not always provide care and treatment in a timely manner. At this inspection we found some people were still waiting for long periods of time before starting treatment or having a medication review. In February 2025, across MHT teams, 2,699 people were waiting for interventions (which included initial interventions, initial meetings, medication reviews and all treatment pathway interventions). Of those 2,699 people, 715 were on waiting lists for Thanet MHT. Of those 2,699 people, 466 people had been waiting for 90+ days. Of the 466 people who had been waiting 90+ days, 120 of them had been waiting for an individual initial intervention, 61 for a group initial intervention, and 60 for an initial meeting. This meant people who used services were sometimes waiting for a long time to start their treatment, during which time they did not receive support from the service.

The community mental health service experienced high demand for MHT. Since July 2024, MHT had an average of 3,631 referrals per month. On 20 March 2025, the MHT service had 2,411 people on waiting lists to start interventions. Of those, 479 people were waiting for an individual initial intervention, 380 people were on the waiting list for ‘Understanding complex emotional difficulties’, 293 people were on the waiting list for ‘Managing emotions’ and 277 people were on the waiting list for ‘Complex trauma 2’. In Thanet, 241 people were waiting for an initial meeting, and in Maidstone, 169 people were waiting for all MHT interventions. Data from the trust did not show how long people had waited for each type of intervention within each team.

In the MHT+ service on 20 March 2025, there were 547 people on waiting lists for different interventions across the service. Of those, there were 344 people waiting for psychology reviews. In March 2025, of 9,594 people who had open referrals with MHT+, 9.6% had not been seen in the last 90 days. This meant their risk or needs may have changed without the service being aware or able to effectively respond to their current need. The adult community mental health service’s policies and procedures did not specify the time period within which people should expect to start an intervention, nor the frequency of contact once within the service.

During our inspection, we observed meetings where staff did not always know the most important and more recent information about people who used services. Caseloads were shared across the teams so staff did not always get to know people who used services very well, including knowing their usual presentation, risks and triggers. Some staff told us they felt the shared caseloads had created a barrier to forming a therapeutic relationship with people who used services, as they were seeing so many different people. Feedback shared by Healthwatch Kent and Healthwatch Medway included people who said that staff had not read their notes or previous documentation and their notes were inaccurate.

Care records were difficult to navigate, and some assessments and plans were incomplete or not found at all. Staff had to read through progress notes to access important information about people, which could take considerable time and contributed to a lack of clear oversight of people’s risk. The difficulty in navigating service user care records did not support one of the NHS’s Community Mental Health Framework for Adults and Older Adults’ key aims to “treat mental health problems… underpinned by a single care plan accessible to all involved in the person’s care.” We observed, and staff told us, this caused staff difficulties in being able to quickly access important information about people so they could understand the persons needs and risks.

We saw evidence of inconsistent approaches to the implementation of the risk evaluation and decision process across the adult community mental health service, with different teams using their own templates for recording their meetings. In the Ashford and Canterbury, Thanet, and Maidstone meeting records, we saw a lack of clear information on risks and rationale for people who used services being included in this meeting, as well as many agreed actions that had no staff member allocated to them. This meant there was not sufficient assurance that people who were identified as being of concern were appropriately supported to mitigate risks.

Staff and leaders told us that since the transformation, and introduction of MHT, the service had become an “open door” to all referrals. This meant that sometimes referrals from GPs were not appropriate. These referrals still needed to be reviewed and assessed, which took time and resource away from people who needed the adult community mental health service. Leaders told us the trust would be undertaking work to improve GPs’ understanding of their services so that more suitable referrals were made. They acknowledged they needed to work on this to help manage people’s expectations about the support the service could provide.

Trusted assessments were carried out for people who needed a more in-depth assessment of their needs and risks, with the aim that this would reduce the need for multiple other assessments in the future. The adult community mental health service did not always know about the level of risk of people on their waiting lists for trusted assessments. This was because the data that the service used to review waiting lists did not provide a risk category for individuals. It was not possible to tell which cases were more urgent without looking at the person’s casefile and referral which could take a lot of time. However, the adult community mental health service had made changes to its staffing to enable clinical pathway leads to have more time to review urgent referrals.

Healthwatch Kent and Healthwatch Medway had received 75% negative feedback from people who used services about waiting times and lists for treatment. Some people said their mental health had declined whilst waiting for treatment and that waiting for assessment or treatment without any contact had made them feel abandoned, which had led to their mental health deteriorating. One carer reported their loved one had waited over a year to see a psychiatrist, during which time their mental health declined. For one person who used services, they told Healthwatch that despite numerous hospitalisations, they had still not started their initial intervention and had to wait 6 months for a medication review.

Some staff told us the adult community mental health service’s duty inbox system caused issues. The service had changed from having separate duty team emails to a central duty inbox with subfolders. We were told that some staff dropped emails into subfolders and misplaced them which meant they were then hard to find. Staff told us this system had caused difficulties in contacting people promptly, which meant they remained on waiting lists without being contacted.

Staff followed the trust’s policy on people who ‘did not attend’ (DNA) appointments. Its Policy and Procedure for “Managing Patients Who Did Not Attend (DNA) and/or Are Unable to be Contacted” was due to be reviewed in February 2024. The trust informed us that all policies linked to the community mental health transformation were being reviewed at the time of inspection and had not yet been officially approved. However, we observed staff following the process during risk evaluation and decision meetings to good effect. People who missed clinic appointments were well supported by the DNA policy and staff followed the welfare check protocol to ensure people’s safety.

The adult community mental health service’s processes sometimes caused delays to people being discharged from the service or being stepped down from MHT+ to MHT. One team held a weekly discharge meeting for which staff had to add the cases they wanted to discuss to a list. Some staff told us there was often a backlog which meant people were not discussed until future meetings. Flow meetings took place at least weekly across the teams, during which managers would review people’s needs. Staff told us, and we observed, that in 1 team, for the multi-disciplinary team (MDT) to step anyone down from MHT+ to MHT, the case had to be discussed in a flow meeting rather than the MDT being able to make the decision at the time.

Within the EIP service, a discharge group was being trialled. The aim was to try to prepare people for discharge and reduce any anxiety they may have about being discharged from the adult community mental health service. This meant people who used services could be provided with the information and support needed for a successful discharge.

The adult community mental health service had effective working relationships with partners to ensure appropriate and holistic support was provided to people who used services. For example, the service’s partnerships with third party organisations meant people had access to a range of services and professionals who could assist them with many different aspects of their life that affected their health and wellbeing, such as housing and employment. They also worked with the child and adolescent mental health service (CAMHS) and identified young people who would need to transfer to adult services. This meant staff were aware of the young person’s needs and risks and were able to support them to transition to adult services successfully.

Staff attended a range of multi-agency meetings. They attended a risk forum once a month in which they met with police, social services and other organisations to discuss people with more complex needs. Staff also attended Multi-Agency Public Protection Arrangements (MAPPA) meetings and Multi-Agency Risk Assessment Conferences (MARAC). This helped ensure the necessary support and risk management could be provided for people who used services.

The community mental health service had recruited 35 assistant psychologists and offered overtime for staff to work through assessment backlogs. Leaders told us this was done to address the service’s complaints about long waiting times.

The service did not always improve people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Most staff were knowledgeable about safeguarding processes and about the risks posed to their service user groups.

The service had clear and robust safeguarding policies and processes. Staff received mandatory training in Prevent, which supported them to identify and stop people from becoming radicalised, supporting terrorism or becoming terrorists. Over 90% of teams had achieved the trust’s target of 90% compliance in Prevent training. Canterbury and Coastal CMHT had 50% compliance in Prevent training, as 1 of the 2 eligible staff members had not completed the training. Safeguarding training compliance across the trust was 95%, though some individual teams within the service had considerably lower rates of compliance. These were Ashford and Canterbury, and Thanet MHTs, which had 0% compliance for both Safeguarding Adults Level Three and Safeguarding Children Level Three training. The 0% compliance was in teams of 1 person, though staff would have completed training as part of their induction. Swale CMHT had 50% compliance in both Safeguarding Adults Level Two and Safeguarding Children Level Two.

The service had a safeguarding champion and deputy who helped develop the skills of front-line staff. Staff we spoke to knew how to raise safeguarding concerns and knew who to approach if they had any queries. Safeguarding data showed the 2 biggest themes for people who used services were domestic abuse and self-neglect. Training had been developed to raise staff’s awareness on domestic abuse and self-neglect. Staff we spoke to were aware of the signs that someone might be experiencing abuse or neglect. Between April 2024 and March 2025, the adult community mental health service supported over 766 people to disclose domestic abuse to enable safeguarding.

The trust had consistent involvement and engagement in local safeguarding forums and had strong involvement in its local Medway Multi-Agency Safeguarding Hub (MASH), where professionals and members of the public could raise concerns about the welfare of children and adults.

Staff could access support from the trust’s safeguarding team. Between April 2024 and March 2025, the adult community mental health service approached the safeguarding team for advice nearly 950 times.

Staff in the adult community mental health service supported local Multi-Agency Risk Assessment Conferences (MARAC). Between April 2024 and March 2025, the service completed 100% of MARAC information requests. During that period, 2457 cases were in relation to the Thanet and Ashford and Canterbury localities. By providing information and participating in MARAC processes, the service contributed to safeguarding adults and children.

However, staff did not always follow the trust’s safeguarding practices. We saw evidence of a lack of safeguarding consideration in the care record of one person whose care we observed. Their care record showed a delay of 8 months between their referral and their first assessment. Whilst waiting for assessment, they contacted MHT to tell them they were experiencing thoughts of suicide, and the team was made aware of safeguarding concerns by social services, but this did not appear to affect their wait time. There were several safeguarding concerns noted that prevented them from being able to access the care and treatment they needed, until the situation escalated to such a point they were in crisis.

The service’s processes to work with people to understand and manage risks often meant the service did not have a current overview of individuals’ risks. This left people who were waiting to access services at risk of avoidable harm if their risks changed without the service knowing.

Demand on the adult community mental health service had increased significantly over the past 12 months and there was insufficient staff to provide all people who used services with appropriate treatment in a timely manner. This meant people waited longer to access care and treatment. The service did not have a waiting list management policy or procedure and used an approach called “waiting well” which put the responsibility onto people who used services to contact the trust or other services when they needed help.

Staff told us they were worried about the lack of risk monitoring whilst people were on waiting lists and some staff told us that incidents of self-harm and suicide had occurred whilst people were waiting for treatment. Some staff told us they had chosen to work over their hours to try to mitigate against the high risks. We spoke with 22 people who used services and 7 carers of people who used services. Seven people who used services and 1 carer said they had waits for assessment or treatment of over a month. The trust initially provided incident records of self-harm between September 2024 and February 2025 which showed that 20-28% of incidents per directorate (which combined older age adults and working age adults) occurred whilst the person was waiting for an intervention, medication review or trusted assessment. The trust later told us that this data was inaccurate and confirmed that 13 people who had used services had self-harmed between September 2024 and February 2025 after waiting for more than 28 days after their referral was accepted to receive both their initial assessment and initial intervention. One of the 13 people had cancelled one of their appointments and 3 people had received crisis support within the 28-day time frame. Of the remaining 9 people, 1 person had waited 87 days at the point they self-harmed.

The adult community mental health service did not always ensure people had updated risk assessments and risk management plans and they did not always work with people who used services to create crisis plans that identified their triggers and support available. Both had been raised in our previous inspection in 2020. We reviewed the care records of 25 people who used services. The inspection team found the records difficult to navigate as information was stored in several places within the electronic record system. We found 5 of the 25 care records had no clear current risk assessment or risk management plan. Staff gave differing explanations about why some people did not have a risk management plan. In 8 of the 25 care records, there was no crisis plan for people who used services, and in 12 of the records, the crisis plan was a generic one which contained contact numbers of services to call in a crisis. The generic crisis plan was used in both MHT, and MHT+, despite the MHT+ providing care and treatment to people with more complex or higher risk mental health problems. The service did not have a crisis plan policy, but their Risk Evaluation and Decision Policy stated that “the crisis care plan must be person centred, detail clear relapse indicators, coping strategies and support numbers reflecting the current situation”. Seven people who used services and 1 carer told us they were not aware of or did not have a care plan.

The trust’s January 2025 audit of care records showed that at Thanet MHT+, only 40% of care plans included clear and achievable interventions, only 33% had been updated since a hospital admission or crisis intervention, and only 40% had a clear and detailed crisis plan. Only 50% of risk assessments had a clear, concise and detailed formulation and only 25% of risk assessments had been updated since a hospital admission or crisis intervention. Medway MHT+ was internally audited from 30 January 2025 to 7 February 2025 and only 50% of care plans were in date, and only 60% had a clear and detailed crisis plan. Only 40% of risk assessments were in date and only 50% of risk assessments had been updated since a hospital admission or crisis intervention. This was not in line with the organisation’s risk assessment policy and meant people’s care plans and risk assessments did not always reflect their current needs or risks.

We reviewed the records of one person who was under the care of MHT, and whose mental state deteriorated so significantly that they had to be detained under section 136 of the Mental Health Act 1983 in a health-based place of safety. A carer told staff at the health-based place of safety that they believed “a lack of follow up from Mental Health Together team may have exacerbated the current situation”.

The adult community mental health service was aware that risk management could be improved and staff at all levels told us they had concerns about effective risk management. At Highlands House we were told the team had made the decision to have their own risk management process for people on treatment pathways, as they felt that it was a risk to have no contact with people who were waiting. They had a support worker on each pathway contact each person once every 8 weeks to ensure that needs and risks had not changed. The team also made weekly contact with wards for patients on the pathway who had been admitted to hospital. This allowed the team to have oversight of people’s current and emerging risks.

The condition of some of the buildings and their technology did not always support the delivery of safe and effective care. However, the trust had plans to improve its estate. The service was aware of potential risks in the care environment and had processes in place to carry out routine maintenance and health and safety checks.

The adult community mental health service did not ensure all its environments were suitable for providing safe care and treatment. Much of the service’s estate looked tired and uncared for, with some buildings in a state of disrepair. Some of the rooms at Coleman House were cordoned off and inaccessible to staff and people who used services because the roof had collapsed in July 2024, which had exposed asbestos. The treatment and therapy areas in Coleman House looked old and tired, with peeling and crumbling walls and multiple outdated paper signs on doors. At Britton House, the areas used by people attending the service, although clean, were bare, impersonalised and lacked comfort. In interview rooms in Britton House, it was hard to always hear what was being said because of the sound quality within the rooms, which caused loud echoes. This posed the risk that people’s private conversations could be heard by others and had been on the North Kent directorate’s risk register since June 2023. We were told that 6 rooms had been recently soundproofed to see if this made an impact. On site, we observed that this had made little impact, and staff reported the same at performance and quality governance meetings.

We visited the Beacon Centre, Coleman House and Laurel House and noted that the heating in some areas was very high, which was uncomfortable. We raised this with staff who told us they could not control the heating and had to raise a request with the estates team to make any changes. In Highlands House, the building was very hot on one side, and staff were waiting to get protective film for the windows to try to reduce the heat.

Some staff told us that Beacon Centre is a 20-minute walk from the nearest bus stop, so it was not always accessible to all people who used services. This was at odds with the trust’s Estates Strategy 2019 – 2024 (2023 Refresh) which stated trust services “need to be located on transport routes that make travel as straightforward for service users as possible”. Staff also told us the road to the Beacon Centre flooded and had potholes which made the building hard to access. The car park at Laurel House was filled with cars at entry and access points, which meant disabled people or emergency services could be delayed from attending to the building or prevented from accessing it altogether. It also posed a risk for the safe and timely evacuation of any disabled people away from the site in the event of an emergency.

Some of the adult community mental health service’s first aid equipment was not well maintained. At the Beacon Centre, we saw a first aid kit in the art therapy room that had its last check recorded as 30 October 2018. We also saw a pocket mask covered in dust that had examination gloves in it which had expired in December 2014. There were also 5 expired finger dressings, one of which expired in 2022 and the others in February 2025.

Environmental audits were not always effective. For example, we reviewed a June 2024 health and safety audit of the Beacon Centre that gave a 100% compliance score for first aid kits, which looked at the contents being in date and first aid posters being clearly displayed and completed. At the Beacon Centre we observed that in the small group room, there was a first aid poster that had no first aiders listed and stated that the first aid box was in the ADL Kitchen, which was a room that no longer existed. The same issues were present on the first aid posters in the new group room and in a service user-accessible corridor. In that corridor was also a fire action board that was unreadable, so in the case of a first aid or fire emergency, people did not have access to the necessary accurate information.

Ligature risk assessments were only conducted in inpatient areas and health-based places of safety and not in adult community mental health services. However, internal audits for adult community mental health services showed staff were required to check that ligature cutters were present at community services locations.

The internet service was not reliable in all of the adult community mental health service’s locations. One member of staff at Britton House told us that their internet was often slow and crashed regularly, which would lead them to lose their work. We were told that a reflective practice session for staff at Heathside Centre had to be stopped on 6 March 2025 due to the internet causing problems. With an increasing number of online interventions being held for people who used services, the poor reliability of the internet presented the risk that people’s treatment could be disrupted and/or delayed, and the quality of their treatment experience reduced. This also affected the timeliness for staff to be able to complete tasks, as access to the trust’s online care record system relied on internet access.

The trust had an Estates Strategic Plan which included significant improvement works to some of their buildings, and the consideration of the closure of others. The plan stated it would address some of the issues at Coleman House and Laurel House in the year 2025/26. It was unclear if there were any plans to fix the poor internet connection at Britton House and Heathside Centre.

However, the Beacon Centre had recently undergone major building works to become the community mental health hub for the area. We observed that the rooms at the Beacon Centre and Highlands House were well maintained, and the environments were clean and welcoming. At Highlands House, there was artwork on the walls, which made the environment feel more therapeutic. The trust had recently replaced all the windows at Coleman House and had plans to further improve the building throughout 2025/26, which included restoring the ceilings and converting a disused kitchen into a new clinic and wellbeing space, as well as creating a cleaner’s cupboard.

The adult community mental health service regularly carried out risk assessments and health and safety checks of the buildings, such as fire alarm tests. We saw evidence that staff raised estates and facilities requests to address any issues in the buildings and carparks. The work logs did not always clearly show what action was then taken.

Building security measures meant that only people who worked in, or were attending appointments at the service locations were allowed to enter. People were ‘buzzed’ into the buildings by reception staff. Entrances to staff-only areas had keypads or fob access entry, that meant only authorised people could access them. Treatment, clinic and therapy areas all had clearly identifiable emergency alarms for staff to use if they needed urgent assistance.

The adult community mental health service took people’s safety seriously. Staff had personal alarms and operated a system that meant the service could easily check their location and safety if needed. All appointments were put in diaries so staff locations and activities could be checked if there were concerns. Home visits were done in pairs. The service operated a signing in and out system that supported staff safety. The EIP service also carried out safety checks at the end of each day.

The service did not always make sure there were enough qualified, skilled and experienced staff to provide safe care. Staff did not always receive effective supervision.

Since the last inspection in 2020 there was still insufficient staff across the adult community mental health service, with multiple vacancies in medical and registered nursing roles, which the service had listed on their risk registers. In February 2025, the service had vacancies for band 6 nurses across all directorates, equivalent to 51.51 full time nursing staff in community mental health and EIP services (excluding West Kent EIP). In February 2025, the service had vacancies of 10.01 full time equivalent in East Kent, and 2 full time equivalent in North Kent, for consultant doctors. In West Kent’s early intervention in psychosis service, there was only 1 psychiatrist for 150 people who used services. Staffing challenges caused delays in people receiving timely interventions and medication reviews. One carer said their loved one could not get a medication review with a psychiatrist and would have to wait 8-12 weeks for an appointment with an advanced clinical practitioner, which was not what they wanted. Staff told us that they sometimes had to cancel people’s appointments due to lack of staff. Cancellations due to lack of staff were not recorded on the trust’s incident recording software, which meant the impact could not be assessed. Staff and leaders told us they felt the service needed more staff, and that staffing levels had a negative impact on staff morale and sickness levels.

Some staff told us that at Highlands House, 2 intervention pathways had no facilitators for people to be able to move on to the next stages of their intervention. This caused delays and disruption in people accessing care and impacted on waiting lists.

To reduce vacancies, some teams changed roles they recruited to, for example making them into more developmental roles. Although managers told us this mitigation helped to reduce staff shortfall, it led to an increase in more inexperienced and junior staff joining teams.This meant more experienced and senior staff sometimes had to provide additional support to colleagues, which led to delays in getting their own work completed.

The trust had an Induction Policy which stated the expectations for permanent, temporary, locum and agency staff and volunteers. Induction comprised a 1-day corporate induction, essential training and local induction. The essential training was mainly e-learning and taught staff how to use their electronic systems. Most staff were positive about the induction they had received. Most staff told us they felt the induction was done well and they had been able to shadow colleagues. However, some other staff told us that in the last couple of years induction had not always fully prepared staff for their new roles, which they felt had negatively affected care people received.

There were low rates of compliance for mandatory training in some teams. The trust policy stated that mandatory training compliance should be 90%. Most teams had 100% compliance for patient safety training. The Canterbury and Coastal Community Mental Health Team (CMHT), had 50% compliance as 2 staff were required to complete the training and only 1 had done so. The adult community mental health service’s internal audit in January 2025 of Thanet MHT+’s depot and olanzapine clinics showed only 33% compliance for administering practitioners having up to date medication competency assessments. In March 2025, there were numerous low rates of training compliance at the following:

Ashford and Canterbury Psychology

• 71% Fire Training - 2 Yearly,
• 71% Infection, Prevention and Control - Level Two (Clinical Staff) – Yearly,
• 57% Moving and Handling Patient – Yearly.

Thanet Psychology

• 67% Moving and Handling Patient – Yearly.

Medical East Kent

• 50% Anaphylaxis – Yearly,
• 50% Basic Life Support Theory – Yearly,
• 50% Fire Training - 2 Yearly,
• 50% Infection, Prevention and Control - Level Two (Clinical Staff) – Yearly,
• 0% Mental Health Act - 2 Yearly,
• 50% Moving and Handling Patient – Yearly,
• 50% Moving and Handling Theory - 2 Yearly,
• 50% Personal Safety Breakaway – Yearly.

Canterbury Coastal CMHT (Note that for this team, there were 2 eligible members of staff required to complete the training.)

• 50% Anaphylaxis – Yearly,
• 50% Antimicrobial Resistance - 3 Yearly,
• 50% Basic Life Support Practical – Yearly,
• 50% Basic Life Support Theory – Yearly,
• 50% Clinical Record Keeping - 3 Yearly,
• 50% Equality and Diversity - 3 Yearly,
• 50% Fire Training - 2 Yearly,
• 50% Health and Safety - 3 Yearly,
• 50% Health of the Nation Outcome Scales (HoNOS) - 3 Yearly,
• 50% Infection, Prevention and Control - Level Two (Clinical Staff) – Yearly,
• 50% Mental Capacity Assessment Recording: Consent to Treatment - 3 Yearly,
• 50% Moving and Handling Patient – Yearly,
• 0% Moving and Handling Theory - 2 Yearly,
• 50% Patient Safety for Staff - Once Only,
• 0% Personal Safety Breakaway – Yearly,
• 50% Preventing Radicalisation - 3 Yearly,
• 50% Rapid Tranquillisation – Yearly, 50% The Oliver McGowan Mandatory Training on Learning Disability and Autism - 3 Yearly.

Thanet CMHT

• 75% Freedom to Speak Up: Listen Up - Training for all Managers - 3 Yearly,
• 72% Moving and Handling Patient – Yearly.

Thanet CMHT Admin

• 75% RIDDOR - 3 Yearly.

Ashford and Canterbury MHT (Note that for this team, there was 1 eligible member of staff required to complete the training.)

• 0% Infection, Prevention and Control - Level Two (Clinical Staff) – Yearly,
• 0% Mental Capacity Act - 3 Yearly,
• 0% Moving and Handling Patient – Yearly,
• 0% Moving and Handling Theory - 2 Yearly,
• 0% Safeguarding Adults Level Three - 3 Yearly,
• 0% Safeguarding Children Level Three - 3 Yearly.

Ashford and Canterbury CMHT

• 50% Rapid Tranquillisation – Yearly.

EIP Shepway

• 67% Medicines Calculation – Yearly,
• 75% Moving and Handling Patient – Yearly.

South Kent Coastal MHT

• 50% Basic Life Support Practical – Yearly,
• 50% Moving and Handling Patient – Yearly.

South Kent Coastal Psychology

• 50% Moving and Handling Patient – Yearly.

EIP Canterbury

• 75% Medicines Calculation – Yearly,
• 56% Moving and Handling Patient – Yearly.

Thanet MHT

• 0% Basic Life Support Practical – Yearly,
• 0% Moving and Handling Patient – Yearly,
• 0% Safeguarding Adults Level Three - 3 Yearly,
• 0% Safeguarding Children Level Three - 3 Yearly.

North Kent Medical

• 75% Accessibility Information Standard - Once Only,
• 75% Anaphylaxis – Yearly,
• 75% Antimicrobial Resistance - 3 Yearly,
• 75% Basic Life Support Practical – Yearly,
• 75% Basic Life Support Theory – Yearly,
• 75% Conflict Resolution - 3 Yearly,
• 75% Equality and Diversity - 3 Yearly,
• 60% Freedom to Speak Up: Listen Up - Training for all Managers - 3 Yearly,
• 75% Freedom to Speak Up: Speak Up - Core Training for all Workers - 3 Yearly,
• 63% Health of the Nation Outcome Scales (HoNOS) - 3 Yearly,
• 75% Infection, Prevention and Control - Level Two (Clinical Staff) – Yearly,
• 63% Mental Capacity Assessment Recording: Consent to Treatment - 3 Yearly,
• 57% Moving and Handling Patient – Yearly,
• 71% Moving and Handling Theory - 2 Yearly,
• 75% Patient Safety for Staff - Once Only,
• 60% RIDDOR - 3 Yearly.

Dartford, Gravesham and Swanley Psychology

• 75% Moving and Handling Patient – Yearly,
• 50% RIDDOR - 3 Yearly.

Swale Psychology

• 60% Moving and Handling Patient – Yearly.

Dartford, Gravesham and Swanley MHT

• 0% Moving and Handling Patient – Yearly.

Dartford, Gravesham and Swanley CMHT

• 74% Antimicrobial Resistance - 3 Yearly,
• 67% Freedom to Speak Up: Listen Up - Training for all Managers - 3 Yearly,
• 75% Medicines Calculation – Yearly,
• 71% Moving and Handling Patient – Yearly,
• 74% Personal Safety Breakaway – Yearly,
• 33% RIDDOR - 3 Yearly.

Medway Psychology

• 67% Moving and Handling Patient – Yearly,
• 67% Personal Safety Breakaway – Yearly.

Swale CMHT

• 63% Freedom to Speak Up: Listen Up - Training for all Managers - 3 Yearly,
• 71% Infection, Prevention and Control - Level Two (Clinical Staff) – Yearly,
• 67% Medicines Calculation – Yearly,
• 59% Moving and Handling Patient – Yearly,
• 50% RIDDOR - 3 Yearly,
• 50% Safeguarding Adults Level Two - 3 Yearly,
• 50% Safeguarding Children Level Two - 3 Yearly.

EIP North Kent

• 64% Anaphylaxis – Yearly,
• 60% Moving and Handling Patient – Yearly.

EIP North Kent Psychology

• 57% Mental Capacity Act - 3 Yearly,
• 17% Moving and Handling Patient – Yearly.

EIP and ARMS Medical North Kent

• 67% Fire Training - 2 Yearly,
• 0% Immediate Life Support – Yearly,
• 0% Mental Health Act - 2 Yearly,
• 0% Moving and Handling Patient – Yearly,
• 0% Personal Safety Breakaway – Yearly.

Medway CMHT

• 49% Moving and Handling Patient.

Medway CMHT Admin

• 71% Personal Safety Breakaway – Yearly,
• 0% RIDDOR - 3 Yearly.

South West Kent Psychology

• 75% Clinical Risk Assessment and Management Foundation - 3 Yearly.

West Kent CMHT

• 67% Rapid Tranquillisation – Yearly.

South West Kent CMHT

• 64% Health of the Nation Outcomes Scales (HoNOS) - 3 Yearly.

Maidstone MHT

• 75% Anaphylaxis – Yearly,
• 70% Moving and Handling Patient – Yearly.

South West Kent MHT

• 67% Anaphylaxis – Yearly,
• 67% Basic Life Support Practical – Yearly,
• 67% Moving and Handling Patient – Yearly,
• 67% MUST Nutritional Screening Tool - Once Only.

EIP ARMS Medical West Kent

• 50% Anaphylaxis – Yearly,
• 75% Basic Life Support Practical – Yearly,
• 75% Basic Life Support Theory – Yearly,
• 50% Infection, Prevention and Control - Level Two (Clinical Staff) – Yearly,
• 67% Mental Capacity Act - 3 Yearly,
• 50% Mental Capacity Assessment Recording: Consent to Treatment - 3 Yearly,
• 25% Moving and Handling Patient – Yearly,
• 75% Moving and Handling Theory - 2 Yearly,
• 75% Rapid Tranquillisation – Yearly,
• 75% Safeguarding Adults Level Three - 3 Yearly.

EIP West Kent Psychology

• 50% Freedom to Speak Up: Listen Up - Training for all Managers - 3 Yearly,
• 25% Moving and Handling Patient – Yearly.

EIP West Kent

• 75% Freedom to Speak Up: Listen Up - Training for all Managers - 3 Yearly,
• 67% Infection, Prevention and Control - Level One (Non-Clinical Staff) - 3 Yearly,
• 35% Moving and Handling Patient – Yearly,
• 65% Personal Safety Breakaway – Yearly,
• 75% RIDDOR - 3 Yearly.

This meant that not all staff had the relevant and most recent knowledge and understanding of subjects that affect people’s care.

Staff had access to a range of training programmes to supplement their mandatory learning. Since the transformation and merger of working age adults and older adults services, staff were supported to shadow colleagues or undertake courses to upskill themselves and be able to provide care to different groups of people who used services.

Managers held supervision meetings with their direct reports at least every 6 weeks and appraisals once a year. The frequency of clinical supervision was dependent on the role. Staff could choose to discuss clinical aspects of their role in managerial supervision if they wished. Specific clinical supervision was recorded separately. Caseloads had to be discussed at least every 3 months. Supervision provided an opportunity to discuss any training and development needs staff might have. We looked at 55 managerial supervision records of clinical and support staff. In those managerial supervision records, clinical discussions were mentioned in 3 records, and 3 records mentioned caseloads being discussed.

The adult community mental health service used bank and agency staff to cover vacancies. From December 2024 to February 2025, 1,302 shifts were covered by bank or agency staff. Of those, 359 agency shifts and 94 bank shifts were in South West Kent Community Mental Health Team. Across the service, 50 shift requests were unfilled by agency staff between December 2024 and February 2025.

The trust acknowledged its staffing challenges and considered how they could impact people’s care and treatment. They reviewed their workforce and vacancies to meet the needs of each team and committed to several initiatives that would support in ensuring safe staffing levels and would increase clinical capacity within teams. Some of these initiatives took the adult community mental health service over the budgeted establishment numbers, for example, the short-term recruitment of 35 assistant psychologist posts and the use of agency staff to increase psychology and nursing support. Increased administration support had also been agreed. A resourcing board met monthly, during which directorates provided each other with solutions to recruitment difficulties and monitored the support that was needed from temporary staffing.

The adult community mental health service piloted new roles before they recruited to them in all directorates. For example, in East Kent, they were piloting 3 care connector roles, which would support in linking people with services offered locally. They planned to introduce the role to all directorates after the 6-month pilot ended and had been evaluated.

The adult community mental health service encouraged interest in advertised vacancies by offering short term and permanent contracts and flexible working opportunities. The service had a workshop planned for the end of March 2025, in which clinical staffing resource would be reviewed to ensure productivity and safety were aligned and that workforce establishments were fit for purpose.

Staff turnover in the community mental health services for working age adults averaged 15.42%, with zero staff turnover in over 75% of roles in the past 12 months.

The trust had commissioned an independent health advisory and delivery organisation to work with them to develop a demand and capacity model for the implementation of the Community Mental Health Framework. The model was finished in November 2023 and showed clear job role and time requirements for each stage of a person’s time in the care of the service, from referral through to intervention/s and discharge. This allowed leaders to plan their staffing levels for the service, dependent on the need of people who used services. However, some staff told us that they felt the establishment numbers were still based on the previous working model and were not sufficient for the new way of working.

Infection prevention and control measures were not always effective across the service. Some of the cleaning records showed that some clinic rooms were not cleaned in line with the service’s expectations.

Cleaning records were not always kept up to date. The cleaning and decontamination checklists at Beacon Centre Clinic Room 1 were not always complete. We reviewed records for the weeks commencing 10 January 2025, 27 January 2025, 3 February 2025 and 10 March 2025. The checklist stated the defibrillator had to be cleaned weekly and after each use, however this was not cleaned on any of the weeks reviewed. The checklist stated the drugs cupboard had to be cleaned inside weekly and outside daily, however this was not done on the weeks commencing 27 January 2025, 3 February 2025 or 10 March 2025. The checklist said the pulse oximeter had to be cleaned daily and after each use, however this was not done on the weeks commencing 3 February 2025 or 10 March 2025. The checklist said the examination couch had to be cleaned weekly and after each use, however this was not done the week commencing 10 March 2025. In a clinic room in the Beacon Centre, we saw an out-of-date infection prevention and control policy on display, which showed it was due for review in July 2024. At Laurel House we saw a sign on display with a 5-star cleanliness rating for the building, which had expired on 30 November 2024.

Some of the therapy rooms in Coleman House had crumbling plaster on the walls and we saw a chair in the large group room at the Beacon Centre with rips in it.

We observed reception and waiting room areas, clinic rooms, therapy rooms, offices, toilets and staff kitchens. The service’s premises were clean, and most areas were well maintained and had appropriate furnishings. Clinic rooms had hand washing facilities and personal protective equipment for staff to use.

The estates work log showed evidence that staff reported issues that might affect infection prevention and control and that these requests were actioned. For example, a request was placed for replacement hand washing sinks in all physical health and clinic rooms at Britton House. Infection control staff had identified that the drainage did not meet infection prevention and control standards and that the tap positioning in some sinks did not allow people proper access to the water. Other job requests showed staff reported whenever there were plumbing issues, or when the condition of flooring made effective cleaning difficult. There were also jobs requested for regular, routine cleaning and maintenance of water tanks and hot and cold-water temperature monitoring.

The service did not always make sure that medicines and treatments were monitored to ensure they were safe and met people’s needs, capacities and preferences. They generally involved people in planning, including when changes happened.

The adult community mental health service had systems and processes in place to safely support people with their medicines in the community. Pharmacy staff were embedded into each team and were actively involved in reviewing people’s care and treatment with medicines. They would support with prescribing, de-prescribing, side effect monitoring, medication reviews, medicines adherence, training other healthcare professionals and were actively involved with monitoring people’s physical health where this could be impacted by medicines. By embedding pharmacy staff, this had allowed medical staff to focus on complex cases, thereby reducing waiting times and improving access to specialist care. Staff had access to remote consultants, for example cardiologists, for support with specialist healthcare advice.

The trust was actively seeking ways to improve people’s experience and compliance with medicines. For example, they had introduced finger prick blood testing in a clozapine clinic which had improved people’s experience. Staff worked collaboratively with GPs to support people who used services with their medicines and physical health. Shared care arrangements were in place to support people on certain medicines. People’s medicines were regularly reviewed by a multi-disciplinary team and concerns could be escalated to a meeting each morning. Cases were discussed, reviewed and actions put in place to ensure people remained safe with their care and treatment. Staff were able to access people’s healthcare information from different services in primary and secondary care. This meant they could make informed decisions about care and treatment and had access to the most up to date information available.

Errors and incidents were discussed regularly by staff within the trust and learning from these was shared widely. Any changes to practice were embedded and reviewed to ensure they were having the desired effect. Medicines optimisation was routinely audited to monitor the quality and safety of the service.In some of the teams, there was robust and frequent monitoring of physical health and side effects. This ensured people were kept safe when prescribed medicines with known risks such as clozapine, lithium and high dose antipsychotic therapies.

We saw inconsistent record keeping in relation to medicines across teams in the adult community mental health service. In one of the South Kent Coast teams, we observed that people’s progress notes did not contain any information about their medications. Staff told us there was a blanket ban on writing prescribed medicines in progress notes. Other teams told us they did not have the same ban in place. The trust confirmed no such ban had ever been communicated to staff and that this was not in line with trust policy.

Not all teams in the adult community mental health service carried out physical health monitoring in line with National Institute for Health and Care Excellence guidance, or the trust’s Antipsychotic Guidelines. The trust initially provided data from January 2025 internal audits of depot and olanzapine clinics at Thanet MHT+ that showed 0% physical health screening within the past 12 months, 0% compliance of 12-week physical health monitoring for newly prescribed antipsychotics, and their clozapine clinic only achieved 70% physical health screening in the past 12 months. The trust later told us that this data was not accurate. They said that only 2 people’s records were checked for physical health checks as part of the audit, neither of which showed a physical health check in the past 12 months. However, the trust stated this was possibly due to a change in physical health check recording. They said that a more accurate reflection of physical health check compliance could be seen on their Power BI reports, which showed that in January 2025, Thanet MHT+ had 63.1% compliance against physical health checks. In February 2025, Thanet MHT+ had 58.5% compliance against physical health checks, which reduced to 53.2% compliance in March 2025.