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

Some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service did not always deploy sufficient staff in the home treatment and rapid response teams, which impacted staff wellbeing and peoples flow through the crisis pathway. At the health-based place of safety (HBPoS) patients were staying longer than the lawful permitted time with no legal basis to hold them. Staff did not always demonstrate the duty of candour and apologise to patients when this happened. The health-based place of safety at St Martin’s Hospital and Littlebrook Hospital did not allow people who used services direct access to outside space and fresh air, which is not in line with the Mental Health Act code of practice. The service had identified action to address this, however, we did not see any timeframe for the completion of works. The rapid response and home treatment teams premises were safe, clean, well equipped, well-furnished and well maintained. Staff assessed and managed risks to people who used services and themselves well. Staff understood how to protect people from abuse and the service worked well with other agencies to do so. Incident reports and care records showed the service managed safety incidents well.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At the health-based place of safety (HBPoS) the service was not always open and honest with people that used their services, and did not always apologise when incidents occurred. However concerns about safety incidents were listened to and safety events were investigated and reported thoroughly.

Staff did not always demonstrate the duty of candour. At the health-based place of safety (HBPoS) the trust had a standard operating procedure for the section 136 suite and this required that staff inform patients when they are held beyond the 24 hour detention period permitted by law. We reviewed 15 care records for this service and 9 of these showed patients were not informed of their section expiring. However, 2 records showed staff had apologised to patients when they were held longer than the lawful period due to the lack of inpatient bed to move the patient to. Across the rapid response and home treatment team service, staff were open and transparent and gave patients and families a full explanation if and when things went wrong. Staff told us they apologised to people who used the services and relatives when things went wrong.

Staff recognised incidents and knew when to report them. Managers shared lessons learned from incidents with the whole team. They gave examples of learning that had taken place following incidents. Staff told us that incidents were discussed in team meetings, multi-disciplinary team meetings and clinical governance meetings. Staff told us about incidents that had occurred in the service and changes that had been implemented in response to lessons learned. Managers attended several weekly and monthly meetings, including clinical governance meetings.

Incidents were investigated thoroughly and discussed at the team meetings. Serious incidents had an immediate response, the service manager or deputy director would attend the site the same day this was reported to speak to the team. Patients and their families were involved in these investigations. Staff received feedback from the investigation of these incidents, and support was offered and provided. Managers held debrief meetings with staff after serious incidents to provide support. Staff discussed the feedback and improvements to patient care at team meetings.

Managers provided staff with a debrief after incidents and staff told us that they found these helpful. There was evidence that changes had been made as a result of feedback.

The service was not always able to maintain safe systems of care. Patients at the HBPoS were staying beyond the lawful permitted time. However, the HBPoS did make sure there was continuity of care, including when people moved between different services. The evidence did show a good standard at the rapid response and home treatment teams. This service worked with people 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 people moved between different services. The trust did not always discharge patients from the place of safety within the 24-hour permitted period of detention. We reviewed 15 patient care records across the 2 places of safety between March and April 2025 and found the 24-hour detention period was breached for 9 patients. Managers told us that delays were caused by a lack of availability of inpatient beds and wider system pressures. However the data that the trust provided did not include the reason for staying beyond the time permitted by law. The trust told us they did not have a reporting mechanism for this. The trust had a policy which outlined the procedures to be followed for the reception, care and assessment of people subject to s136 of the Mental Health Act (MHA). This stated that once the lawful period of detention had expired the patient was to be informed of their rights that they are no longer detained under the MHA and seek their agreement to remain and await admission. This was to be reported as an incident and escalated appropriately. If the patient did not consent to remain in the HBPoS then any further action, including whether to continue to detain the patient and provide medical treatment, needed to be based on documented multidisciplinary team discussions. Data supplied by the trust told us that between March 2024 and February 2025 the average length of time patients spent in the health-based place of safety was 42 hours. Staff demonstrated understanding of the use of restraint or restrictive practices as a last resort. Managers at the rapid response and home treatment teams told us that restraint or restrictive practice was not used by the service. Staff undertook restraint training. At the time of inspection 94% of staff in the Maidstone home treatment and rapid response team had completed this. At the time of inspection, the 2 patients at the Priority House health-based place of safety had been restrained and had received rapid tranquilisation after the section 136 authority to detain had expired. These patients were not held under any legal framework. The health-based places of safety was available 24-hours a day. Staff assessed patients promptly once they arrived at the places of safety. On arrival at a health-based place of safety, patients were searched by the police and any items that may have been dangerous to a person’s health and safety were held in storage. The target time for commencing an assessment under the MHA was 4 hours. After the assessment had been carried out and 2 medical recommendations obtained, the ‘bed-flow’ team was asked to locate an inpatient bed. The assessing approved mental health professional (AMHP) returned once the bed had been identified to complete the application. This could also be completed remotely and sent through electronically. However, sometimes, if the assessing AMHP was no longer available, another AMHP visited the HBPoS and determined, based on the time that had lapsed, whether a fresh assessment under the MHA was required. Data provided by the trust showed that from March 2024 to February 2025 the average time for arrival in the health-based place of safety to assessment was 35 hours. The manager of the health-based places of safety told us they could access AMHP’s and doctors to ensure people who used services were assessed under the Mental Health Act 1983 (MHA) in line with legislation. However, they also told us that if a patient had been assessed as needing an inpatient bed, there were delays finding beds in the inpatient services and so the patient would have to remain in the HBPoS until a bed was found. The service had clear criteria to describe which patients they would offer services to. The place of safety accepted referrals for patients aged 18 or over. For children and young people, referrals went to the children and adolescent mental health service (CAMHS) home treatment and rapid response team who then informed the AMHP service. An AMHP is a role under the Mental Health Act in the UK, referring to a qualified and experienced mental health professional who has been approved by a local social services authority to carry out duties related to the compulsory assessment and detention of patients under the Act. The manager said that this usually happened in a timely way but on occasion referrals could be delayed. The service did not accept patients when there were concerns about their physical health. The police took these patients to an emergency department of an acute hospital for medical assessment before taking them to the place of safety. There were interagency quarterly meetings to monitor the performance and issues with the HBPoS. These were attended by trust managers, integrated care board members, police, local authority and other trusts. We reviewed actions from these meetings. For example, it was identified that AMHP’s should be involved in the work on a new centralised HBPoS. The trust identified the right people to be involved and they were brought into the project by December 2024. Across the rapid response and home treatment teams, staff involved all the necessary healthcare and social care services to ensure people who used services had continuity of safe care, both within the service and post-discharge. Staff followed the trust policy on people who did not attend, unable to attend or ‘was not brought’ appointments including non-access domiciliary visits and where a person had left mid-appointment. The policy provided a framework for staff to follow in such circumstances and was based on a trauma informed approach to care and treatment. Staff followed a process including contacting the person, their next of kin and they left a card to contact the service due to the person not being there. If no contact was made during the shift, the rapid response team would be asked to complete a welfare check, and if they could still not establish contact the person would be reported as missing to the police. The rapid response and home treatment team’s service’s referral and admission processes ensured that all essential information about people who used services was received to determine if their needs could safely be met. Staff reviewed essential safety and risk information about people who used services in twice daily multidisciplinary meetings. These meetings included plans to safely meet people’s needs and discharge planning. We observed 3 meetings and saw robust risk discussions of each person on the team caseload. Staff demonstrated a good understand of each person’s risks and planned care and treatment. Staff worked with community teams to ensure continuity of care, when people who used services were seen by both community services and home treatment and rapid response teams. Teams were able to refer to community teams where appropriate. Teams used systems to categorise risk each day and identify high risk people who used services, and took appropriate action to support these people.. We reviewed 19 records for people using the rapid response and home treatment team services. They showed risk assessments were completed, reviewed, updated when new information was received, and they were used to support care and treatment.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s 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 from the home treatment and rapid response services understood how to protect people and patients from abuse and worked well with other agencies to do so. Staff told us they could access support from the trust’s safeguarding team when they needed it. This included working in partnership with other agencies. Staff reported good working relationships with local authority safeguarding teams and had worked with other agencies such as the police to safeguard people. Staff had training on how to recognise and report abuse and they knew how to apply it. At the time of our assessment, 100% of staff had completed their safeguarding adult’s level 2 and level 3 training. All staff had completed safeguarding children level 2 and level 3 training. Staff knew how to recognise adults and children at risk of or suffering from harm. Managers of the home treatment and rapid response services told us the main safeguarding theme for people who used their services was child welfare. We observed staff identifying safeguarding concerns during the morning planning meetings. Staff knew who the trust leads for safeguarding adults and children were and how to contact them for advice. Managers received alerts for each safeguarding referral so they can keep track of them. Managers reviewed alerts within 48 hours to follow up on outcome and learning. Ther service had a safeguarding policy that included an escalation policy.

The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to people who used services and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff at the health-based places of safety (HBPoS) used restraint and seclusion only after attempts at de-escalation had failed. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Staff carried out comprehensive assessments of people who used their services’ mental and physical health needs. We reviewed 24 patient care record across the rapid response and home treatment teams and health-based places of safety (HBPoS). These showed risk assessments were completed and updated regularly and appropriate risk management plans put in place. They showed people who used services were involved in their risk management plan with their views highlighted and a strengths-based approach used in line with their care plan. We reviewed 12 patient care records for the home treatment and rapid response teams. Staff formulated an initial care plan with people who used services when they were admitted into the service. Carers and family members could be included in this if the person consented. All records we reviewed demonstrated people who used services and their carers involvement. Staff reviewed and updated care plans weekly or when people’s needs changed. All records we reviewed had a safety plan in place. Mangers carried out a monthly care record audit which focused on risk assessment, care and crisis planning. Staff involved people who used services in care planning. We found evidence of people who used services and carer involvement in all care plans we reviewed. We spoke to 6 people who used the home treatment and rapid response services. Four people told us they were given a copy of their care plan. However, 2 people said they had not received this. Care plans were written in a way that people who used services could understand. Medicines care and treatment plans were well documented throughout people’s care records. They were detailed and included information about physical health monitoring, side effects and actions for staff to take to ensure people were kept safe when taking medicines. Staff performed a full physical health assessment on people who used services. The teams had physical health nurse in place who also took the lead on wellbeing. At the time of inspection, the teams had implemented a clinical quality audit including physical health. At the place of safety, the duty doctor completed physical health screening of all patients who gave consent. Patients had their physical health assessed prior to admission to the HBPoS and were taken to the emergency department for any concerns before admission. Patients had their physical health monitored closely while they were in the HBPoS

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. However, at 2 of the HBPoS there was no access to fresh air. At the health-based places of safety (HBPoS) all clinical premises where patients were seen were safe, clean and well maintained. Staff visited most people at their homes or in community settings. The Maidstone home treatment and rapid response service had a room on premises where people could be seen, however managers told us this rarely happened as most people elected to be seen in their homes. This room was clean and fit for purpose. Managers told us there were plans to make this room more welcoming by improving the décor. The layout in all of the health-based places of safety (HBPoS) allowed staff to observe all areas. There was closed-circuit television (CCTV) which allowed staff to observe internal and external patient areas. There were no potential ligature anchor points, and each HBPoS had a ligature risk assessment. There was a comprehensive environmental check list that was completed weekly. The observation panel for the seclusion room in the HBPoS at Priority House was in the nursing station of the HBPoS. At the HBPoS, all the facilities were clean and tidy. Staff cleaned and checked the rooms after each patient was discharged. However, at the HBPoS at St Martin’s Hospital and Littlebrook Hospital patients had no direct access to outside space and fresh air which was not in line with the Mental Health Act Code of Practice. The trust’s Estates Strategy outlined plans for a new 5-bedroom HBPoS to be built at Priority House. The matron for the service confirmed that funding had been approved via a joint bid from the trust and the integrated care board for the area, and that building works was soon to be commenced, however there was no date for completion set at the time of inspection. Staff had easy access to alarms including wearing personal safety devices that connected them to each ward, and lone worker devices. Staff did regular risk assessments of the care environment, and all buildings had a local site-specific risk assessment. We reviewed the site-specific risk assessment for all of the home treatment teams and HBPoS. Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. Staff checked equipment and temperatures daily. Staff completed and regularly updated thorough risk assessments of all areas and removed or reduced any risks they identified. Annual environmental risk assessments were completed for each of the home treatment team sites.

The service did not always make sure there were enough staff. Staff did not always receive effective supervision. The trust was aware of its staffing and recruitment challenges and had taken action to improve the situation. At the time of our inspection there were several vacancies across the rapid response and home treatment teams. Staff told us there were often challenges with staffing and this had an impact on their wellbeing. In the Dartford team there were 3 Band 6 nurse vacancies the time of inspection. In the Medway and Swale team there was 1 consultant and when they were not available there was limited cover available. After our visit the service started a rolling rota with trust consultant's to be on call, and the service was in the process of recruiting consultants to this service. There were also several occupational therapy practitioner vacancies. In the Maidstone team there were vacancies for 1 Band 6 nurses, a Band 5 nurse, a part time social worker and part time social worker assistant, 1 Band 6 occupational therapist, 2 peer support workers and an administrator. In the North East Kent team and South East Kent team there were vacancies for 2 Band 6 nurses, 1 Band 5 nurse, 5 support workers and 1 Band 6 occupational therapist. Medical cover for the North East Kent team was provided by a 6-month rotational doctor. Staffing vacancies were identified as a risk to the service and were on the risk register. This had been on the risk register since June 2023. This risk had been rated and had gone down since it was initially flagged. The pharmacy team were well integrated into the home treatment teams and staff told us they valued these teams for their support. However, pharmacy staff told us that people who used their services would benefit from being funded for more time dedicated solely to the home treatment teams as there would be greater input on medications. Pharmacy staff told us they did not have sufficient staff to complete medicines reconciliation for every person so prioritised this work based on risk. This was not in line with current trust policy. The trust told us they were amending the policy to reflect that the pharmacy team would only do a full reconciliation for people on the case load of the home treatment team who are prescribed high-risk medicines. . For the HBPoS, pharmacy staff were available but had no dedicated time set aside to support this service. This meant this work was not prioritised and delayed. When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. Data the trust provided to us showed that between December 2024 and February 2025 in the North East Kent rapid response and home treatment team 200 shifts were filled by bank staff, and 80 shifts were filled by agency staff. For the South East Kent home treatment and rapid response team 197 shifts were filled by bank staff and 53 shifts were filled by agency staff. For the Dartford home treatment and rapid response team 323 shifts were filled by bank staff and 142 shifts were filled by agency staff. For the West Kent home treatment and rapid response team 293 shifts were filled by bank staff and 56 shifts were filled by agency staff. For the Medway home treatment and rapid response team 194 shifts were filled by bank staff and 4 shifts were filled by agency staff. The service used bank and agency staff to fill gaps in shifts due to leave or sickness. Several substantive staff were in this bank pool of staff and filled shifts within their team. Managers told us due to the specific work of the teams they preferred staff who had worked within this or another home treatment and rapid response service before. Managers gave all temporary, agency and bank staff a local induction if they had not worked at the service previously. All staff were first required to work a shadow shift. This is a shift were the new staff member shadows a current staff member to observe and learn about the role. The service had an induction book that included a checklist, policies, requirement for care record completion, and the process to follow if they were unable to make contact with a person who used the service. Whenever possible, the service used long-term agency staff who were familiar with the service. We raised concerns about staffing levels during our inspection. Managers and senior leaders were very aware of the risks due to staffing vacancies, and they told us this was the top risk for the service. Managers told us there was ongoing recruitment and new staff were due to start. If there was a short notice unfilled shift this was reported as an incident. Managers and senior leaders told us recruitment was difficult due to the geographical area that was covered by the service. Another challenge was the delays in staff obtaining disclosure and barring service checks. Mandatory training was comprehensive and met the needs of staff and people who used services. All of the staff we spoke to told us they were up to date on their mandatory training. The North East Kent and South East Kent home treatment and rapid response team were at 97% compliance with their training. The Dartford home treatment and rapid response team was at 96% compliance, the Medway home treatment and rapid response team was at 94%, and the West Kent home treatment and rapid response team was at 91% compliance. All teams were above the trust target of 90% compliance with mandatory training. Team managers told us that regular agency and bank staff also completed trust mandatory training. Managers and staff told us they received combined clinical and managerial supervision every 6 weeks. The North East Kent home treatment and rapid response team was at 74% compliance for supervision. The Dartford and West Kent home treatment and rapid response teams were at 59% compliance, the Medway home treatment and rapid response team was at 43% compliance, and the South East Kent home treatment and rapid response team was at 41% compliance. The trust had introduced a combined clinical and management supervision. The home treatment and rapid response service had a supervision tree where senior members of the team provided supervision for junior members of staff. Managers told us staff discussed clinical cases during supervision. Staff also did reflective practice during daily multidisciplinary meetings. Bank and agency staff were also offered supervision. Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. For example, managers and staff told us they had identified a need for further training to support autistic people and people with a learning disability due to the increase in people presenting with these diagnoses.

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.

We looked at clinic rooms, consultation rooms and reception and waiting areas at the locations we visited. All were visibly clean and tidy.

Cleaning records were up to date and demonstrated all areas were cleaned regularly. The service had appropriate policy and guidance for staff to follow in relation to preventing and controlling infections.

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. The service was actively implementing ways to improve people’s outcomes and experiences with their medicines.

The service had systems and processes in place to safely support people with their medicines in the community and when accessing health-based places of safety (HBPoS). However, staff at St. Martin’s Hospital HBPoS were not always following these processes. People were not getting their prescribed medicines when staying in the HBPoS and medicines were not being stored safely. There was an incident at St Martin’s Hospital HBPoS where we found medicines were being stored improperly in the nurse’s office. We raised this with the trust at the time of the inspection and they were responsive in resolving issues and ensuring people were kept safe. This was reported as an incident, a staff memo was sent to remind staff of correct storage processes, and enhanced monitoring through weekly audits was put in place.

Pharmacy staff were embedded into each home treatment team. They provided expert support to the teams on all aspects of medicines optimisation. This included visiting people in their home to perform clinical reviews and support them with their medicines, side effect monitoring of prescribed medicines, monitoring of peoples prescribed medicines with known health risks and liaising with other healthcare professionals. Staff used nationally recognised tools to document and record this information. The pharmacy team supported the rapid response and home treatment teams with ways to improve compliance and adherence with medicines. Staff in the home treatment teams worked collaboratively with GPs to support people with their medicines and physical health. Shared care agreements were in place to support people on certain medicines, for example Lithium, where appropriate. A shared care agreement is a written agreement between a patient, their general practitioner (GP), and a hospital consultant that allows for the sharing of care for a specific health condition. The agreement details the responsibilities of each party, including who is responsible for prescribing, monitoring, and early referrals. Staff reviewed the effects of each person’s medicines on their physical health according to NICE (National Institute for Health and Care Excellence) guidance.

People’s medicines were regularly reviewed by a multi-disciplinary team when under the home treatment team. Concerns could be escalated to a meeting each morning where 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. Medicines 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 audited every 6 months to monitor the quality and safety of the service. The trust provided us with the results of these audits, however this was for each of the directorates and did not specify what team these applied to.

People were able to obtain medicines information in a variety of formats. This included easy read, different languages and the ability to use translation services

The service was actively implementing ways to improve people’s outcomes and experiences with their medicines The pharmacy team were undertaking a quality improvement project after identifying that people were not getting the information they needed on their medications. They had created a poster with a QR code that linked to a website that offered information about their medication.