Lancashire & South Cumbria NHS Foundation Trust

Updated 31 January 2024

Lancashire and South Cumbria NHS Foundation Trust provides a wide range of specialist mental and physical health services to a population within Lancashire and South Cumbria. The trust has 25 registered locations which provide inpatient and community care. The trust has approximately 949 inpatient beds across 57 wards and serves a population of around 1.8 million people.

The trust employs approximately 7,000 members of staff and had an annual operating income of over £500 million for 2022-23.

The trust provides the following core services:

• Acute wards for adults of working age and psychiatric intensive care units (PICU's)
• Long stay/rehabilitation mental health wards for working age adults
• Forensic inpatient / secure wards
• Wards for older people with mental health problems
• Community-based mental health services for adults of working age
• Mental health crisis services and health based places of safety
• Specialist community mental health services for children and young people
• Community-based mental health services for older people
• Community mental health services for people with a learning disability or autism
• Community Dental Services
• Child and Adolescent Mental Health wards
• Community Health Inpatient services
• Community Health Services for adults

• Community Health Services for Children and Young people
• Community End of life Care

We carried out unannounced inspections of wards for working age adults and psychiatric intensive care units and 2 short notice (24 hour) inspections of the community based mental health services for adults of working age and the crisis and health based places of safety core service provided by this trust.

We also inspected the well-led key question for the trust overall.

• We inspected 18 wards for working age adults and psychiatric intensive care units across all 7 inpatient sites and 5 locations of the community based mental health services for adults of working age. We visited these services because we had concerns about the pathway of care including waiting times to access community based mental health teams, risk management of community based mental health patients and access to working age adults and intensive care unit inpatient beds.
• We inspected the crisis and health-based places of safety. During this inspection we visited 5 home-based treatment teams, 2 mental health liaison teams, 2 mental health urgent assessment centres, 2 health-based places of safety, 2 Initial response services and 1 street triage team. We inspected this core service because at our last inspection in 2020 we rated the service as inadequate overall and needed to ensure the quality of care had improved.
• We did not inspect long stay rehabilitation mental health wards for working age adults or wards for older people with mental ill health which are also rated requires improvement, because we have not been in receipt of information of concern since our last inspection of these services.
• We did not inspect community health services for adults because we have not been in receipt of information of concern since our last inspection of these services.

We are monitoring the progress of improvements to these services and will re-inspect them as appropriate. All other core services provided by the trust were rated good at the time of our inspection.

Overall, we rated safe and effective as requires improvement and caring, responsive and well-led as good.

Our rating of trust improved. We rated it as good because:

• We previously rated 10 of the trust’s core services as good overall and 5 as requires improvement. We previously rated 14 of the core services as good in the caring key question with one service rated as outstanding. We previously rated 14 of the core services as good in the responsive key question. Although we found some areas for improvement in leadership and management within some of the services we inspected, we were sufficiently assured of the trust’s overall leadership, management and culture following our trust-wide well-led inspection.
• The Crisis service and health-based places of safety had significantly improved since our last inspection in 2020 where we had rated the service inadequate. Following transformation of this core service the crisis service had improved to good.
• Leaders were experienced, visible and approachable. Leaders had implemented improvements since our last inspection. The trust had implemented a transformation programme which was planned across the adult mental health acute care pathway.
• Executives and non-executives were passionate about the trust’s delivery of safe, high-quality care, they were aware of the trust’s challenges and risks. An improvement plan which included an increase to bed capacity had already begun and a model of care to increase community support was in progress.
• The trust had a clear vision and strategy, understood by all staff and driven by the executive team. We were able to see progression towards the trust’s achievement of its strategic goals. Staff demonstrated the trust’s values in the care they provided.
• The trust had a strong freedom to speak up process which staff spoke about positively. Staff equality networks had been successful implemented and supported staff through development initiatives. A ‘flex’ system had been introduced to enable individuals to work flexibly, this supported staff retention and showed value of the workforce.
• The trust had made improvements to its information management systems this included the implementation of DIALOG+ to support patient-centeredness, care planning and goal-based outcomes. A significant financial investment had been ringfenced to implement a patient record system within community health services, this also supported partnership working with other stakeholders such as GP’s.
• The trust had implemented a recognised Quality Improvement methodology with a clear and embedded approach to quality improvement which involved staff at all levels, we were able to see examples of where quality improvement approaches had been used to make improvement at both services and trust-wide level. Quality improvement was part of the mandatory training programme.
• System wide work with partner organisations was evident with a shared health and care approach. This included work to support both the workforce and the care and treatment of those accessing services.
• The trust commissioned an external well led review in 2022 and have implemented an action plan to drive improvement.

However:

• Since our last well led inspection in 2019 the trust had reviewed and implemented new clinical models and had developed transformation programmes to support this. This was still in the implementation stage and was not yet fully operational.
• At this inspection we rated 2 of the 3 core services we inspected requires improvement overall and one of the core services as good overall this was an improvement from inadequate at our last inspection. In rating the trust, we considered the current ratings of the 12 core services we did not inspect this time.
• The trust did not always have enough suitably trained staff to deliver safe care in all services. This was due to high vacancy rates, high but improving sickness rates and significant reliance on temporary staff in some services. However, there were clear plans with evidence of delivery in increasing the number of Care Hours Per Patient Day in inpatient wards and increasing the establishment and recruitment to this new establishment in Community Mental Health Teams and Home Based Treatment Teams.
• There was low compliance with supervision and annual appraisals although this was improving. Overall, the trust had a supervision compliance rate of 76% including staff on long term sick and new starters and an overall appraisal compliance rate of 80%. There was a clear and structured approach to supporting staff through a newly-introduced Appraisal Cascade approach, which ensured that individual objectives aligned to trust objectives. At the time of the inspection, the roll out of Appraisals since April had reached 80.2% against a target of 80%.
• People continued to wait too long to access some services. Waiting times for Community based mental health services for adults of working age had improved since the last inspection however there was not enough nursing and multidisciplinary staff in some teams, and this impacted on service delivery such as waiting for a care coordinator. Current bed capacity within the trust meant there were high risk individuals who had been deemed appropriate for admission but were unable to access an inpatient bed. There were also significant waiting times in specialist community mental health services for children and young people including access for neurodevelopmental assessments. The trust was working with the integrated care board to improve access to services.
• The capacity in acute wards for adults of working age and psychiatric intensive care units was lower than the demand, which had led to higher than expected out of area placements and an increase in demand for community based mental health services for adults of working age. This may have impacted upon the experience of those in community services.

How we carried out the inspection

Before the inspection visit, we reviewed information we held about the trust. During the inspection visit, the inspection team:

• visited all 18 of the trust’s acute wards for adults of working age and psychiatric intensive care units across all 7 inpatient sites.
• visited 5 out of 13 community based mental health teams for adults of working age.
• visited 5 home-based treatment teams, 2 mental health liaison teams, 2 mental health urgent assessment centres, 2 health-based places of safety, 2 initial response services and 1 street triage team.
• spoke with 118 members of staff.
• spoke with 52 people using the trust’s services.
• spoke with 23 carers or relatives of people using the trust’s services.
• reviewed 143 care records including medicines administration charts.
• observed several meetings including multi-disciplinary team meetings, safety huddles, multi-service calls and a multi-agency call and handover of care meetings.
• conducted 10 observations of direct practice.

• observed 1 sub-committee of the board as well as 1 board meeting.
• held 10 focus groups with staff and governors.
• spoke with 30 members of the trust’s leadership team including members of the board, the chair, and the chief executive.
• sought feedback from a range of stakeholders including health watch and the integrated care board.
• reviewed the trust’s process for fit and proper persons employed.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

Community- based mental health services for adults of working age

Patients we spoke with told us staff had warm and friendly attitudes towards them and most patients said staff were responsive.

Patients felt they were well informed in relation to their diagnosis, treatment, and care plans. Patients we spoke to confirmed they felt involved in their care.

Patients said they felt they trusted staff and they had a good rapport with their care coordinators. Patients described staff as lovely, polite, helpful, and well organised.

Feedback from friends and family was overall very positive. There were a small number of negative comments relating to poor communication and waiting too long to access the service.

We also spoke specifically to patients who had experienced being on the unallocated waiting list. Most patients said they were not contacted regularly by the service; telephone calls were not returned and they did not have care plans or crisis plans to refer to.

Mental health crisis services and health-based places of safety

We spoke with 11 patients who used the service. Patient feedback was generally positive. Patients viewed staff as kind, caring and considerate. Patients told us that the service was generally responsive and had helped them when they needed it.

Acute wards for adults of working age and psychiatric intensive care units (PICU's)

Most described staff positively and said they were caring and supportive and treated them with dignity, kindness, and respect. They described being able to speak to staff about any issues that were troubling them and being afforded privacy to do this.

Patients told us they were offered a copy of their care plans and given information about their care and treatment.

Patients said there were generally enough staff around, but they were always very busy, with three patients saying there were not enough staff. One patient told us their leave had been cancelled and one patient told us that activities were cancelled due to a lack of staff.

Most patients were happy with the activities, food, and ward environment.

Trust wide

Integrated Care Board

Feedback from the integrated care board (ICB) noted a significant change to the trust leadership and culture. The integrated care board felt the trust had developed into a transparent and honest organisation which had developed positive relationships with the ICB team and key stakeholders including local authorities, police, voluntary sector, ambulance and acute colleagues. The ICB felt they were promptly informed of any emerging risk and that relationships were good.

The ICB was aware of the shortfall in inpatient bed numbers but felt that following the opening of the new wards based at the Whalley site the shortfall would be considerably reduced. The ICB confirmed their support for a move away from an acute delivery system model to a community system.

Health Watch

During our well led inspection we held a focus group with representatives from Healthwatch they told us that feedback was a main driver at the trust and they were Inviting positive and negative feedback. They described been invited to quality visits on the inpatient units and feeling listened to when providing feedback.

They felt the change was on the back of the new leadership team.

We heard some concerns regarding the crisis line and some patients experience of using this.

Updated 11 January 2017

Overall, we have rated community health services for adults as “Requires Improvement”. This is because:

• We were not assured that all lessons learnt were being identified in the root cause analysis investigations we reviewed or areas identified for improvement were being monitored.

• In the Integrated Nursing Teams (INTs) in Chorley and South Ribble, and Blackburn with Darwen localities, we found 18 out of 20 patients records where patients had died, that did not have an end of life care plan in place.

• In Chorley and South Ribble INTs and the treatment room service, there were not always care plans in place for problems that had been identified. We found incomplete assessments, wound evaluation charts not updated at least fortnightly in line with the trust management of wound’s policy, and not all entries had the time of entry documented.

• Data for mandatory training and appraisal rates provided by the trust was not as accurate and up to date as data held at team level.

• An audit had been performed to monitor storage of medicines and had reported issues with clinic room temperatures not being monitored which we observed at the time of our inspection and we were not assured that clear actions and improvements had been made. When staff had raised issues with the temperature recordings being high in clinics and treatment rooms, as per the trust policy, no action had been taken.

• The Integrated Nursing Teams (INTs) were not using a staffing acuity tool and of the seven INTs we visited we found two that mentioned the use of a caseload weighting tool. Since our previous inspection the trust had been reviewing potential tools and had analysed activity data to inform a new model of care. Due to on going transformation work at the trust, the business case for staffing against activity had been placed on hold.

• We requested documentation audits specifically for the INTs and were informed by the trust that the INTs had not participated in a documentation audit for the 12 months prior to our inspection. Documentation issues had been highlighted in root cause analysis investigations in relation to pressure area care.

• The trust data identified that a total of 575 pressure ulcers had developed whilst patients were on the services caseloads. There were 13 of these that deteriorated which suggest that once a pressure ulcer developed care and prevention strategies were implemented to prevent any deterioration. We were not assured that prevention strategies were put in place to prevent the development of pressure damage. During our inspection we found care plans and risk assessments were not always in place or updated and this was also identified as part of a root cause analysis investigation.

• Systems in place to ensure staff were safe at the end of an evening shift were not always followed.

However:

• The trust had a range of mandatory training available to staff and staff compliance met the trust target of 85%.

• Staff had an annual appraisal where learning needs were identified. The trust provided opportunities for staff to develop which included placements at education establishments. Developmental roles for band five nurses had been implemented for staff wanting to develop into leadership roles. This also assisted the trust to develop and recruit senior nurses from within their own workforce.

• There was good evidence of services and disciplines working together to improve services for patients and included: the intensive home support service, the discharge planning team, the Care Home Effective Support Service (CHESS) Team and the diabetes service.

• People who used the services were able to ask questions, discuss care, and were involved with decision making. The services received positive comments about the staff and the care provided and patients were treated with dignity and respect.

• There was evidence of delivering services to meet patient’s needs. There had been a review of the community matron service which identified the need for specialist Chronic Obstructive Pulmonary Disease (COPD) services and rapid access to care to prevent hospital admissions. There was evidence of multi-agency and patient focus groups to inform delivery of services which resulted in a more integrated approach to service delivery via the intensive home support service.

• Podiatry services had implemented a one stop assessment for patients who may require nail surgery which resulted in a reduction of additional appointments for patients and an increase in podiatry staff availability. The service had direct access to a vascular surgeon where they could arrange urgent appointments and the service could order diagnostic tests prior to the patient attending the appointment to enable the consultant to have sight of all information at the time of consultation.
• Staff felt supported and listened to and there was professional forums for nurses and allied health professionals.

Updated 11 January 2017

Overall, we have judged that community health services for children, young people & families is “Good”. This is because:

• Staff knew how to report incidents and reported receiving feedback in a number of ways. Staff could describe incidents that had been reported and identified actions taken in response.

• The trust had implemented “Risk sensible” approach safeguarding training for all practitioners in the children and families network. This assisted with the identification of risk and enabled effective communication with social care colleagues using a common language.

• Paper and electronic records we reviewed were completed to a good standard and included relevant patient information including name, address, date of birth as well as care plans, referrals and safeguarding information as appropriate.

• All clinical areas we visited were visibly clean. We observedhandwashing and infection control practices in home visits and at a baby clinic, appropriate cleaning of equipment between patients and use of personal protective equipment.

• Caseloads in universal services for children and young people were weighted to ensure a standardised approach to decision making across the trust and the weighting of each child was clearly identified on the electronic care record (ECR).

• The service used National Institute for Health and Care Excellence guidelines to determine care and treatment. Health visiting and school nursing teams worked to deliver the Healthy Child Programme and two of the five contacts were delivered using the Ages and Stages evidenced based screening tool.

• Health visitors used tablet computers to access records and document contacts while in clinic settings or during family visits. The use of internet software allowed staff from across bases to connect in to daily huddles without the need to travel and ‘Chat Health’ was being introduced across the school health service which allowed students and parents to contact the school health service by telephone and text in a confidential and accessible manner.

• We observed several examples of multi-disciplinary working during our inspection, in both health and education settings, with clinicians collaborating to support the planning and delivery of care to children, young people and their families.

• Contacts we observed showed information provided to children and families was clear and tailored to the individual child. Families were offered choice regarding their child’s care and given the opportunity to ask questions. Families engaged with the Children’s Integrated Therapy and Nursing Service were involved in writing their child’s care plan.

• The Children’s Integrated Therapy and Nursing Service staff arranged joint visits to families to reduce the need for attendance at multiple appointments and health visitors in the West Lancashire area had returned to individual allocation of community clinics to promote continuity for families in response to service user feedback.

• The Family Nurse Partnership was offered in the Preston and Burnley area to first time mothers aged 19 years and under to improve health, social and educational outcomes. Identified liaison health visitors were in post to provide support and advice to families placed in a refuge and safeguarding specialist nurses worked in partnership with other agencies to provide health assessment, advocacy and support for children and young people involved with the youth offending team or identified as being at risk of child sexual exploitation.

• The Clinical Director for the children and families network provided a monthly quality and performance report to the Quality and Safety sub-committee and performance was monitored against a variety of targets and data. Staff we spoke with were aware of the key performance indicators relevant to their role and individual performance was reviewed in monthly one to one meetings with their line manager.

• We observed strong leadership from team leaders and managers and staff spoke positively about the team leaders, describing them as visible, accessible and supportive. Monthly team meetings took place to ensure staff received information and feedback regarding incidents and complaints and were kept informed of developments within the trust.

• The safeguarding team were not routinely being copied in to referrals made to children’s social care. This meant that managers did not have an accurate picture of safeguarding activity across the trust.

• Safeguarding supervision was practitioner-led and delivered in a group setting where each practitioner would bring one case to discuss. While safeguarding specialist nurses were available to provide telephone advice and team leaders were available for ad hoc support, this meant that not all safeguarding cases were subject to objective, critical reflection.

• At the time of our inspection the antenatal contact was not being delivered consistently to all pregnant women in the trust. Staff and managers told us that there were delays receiving information about patients accessing antenatal care from local acute providers and this was recorded on the trust risk register.

• Annual appraisal rates for non-medical staff in community health services for Children, Young People and Families was 73%. Compliance rates in individual teams ranged from 29% (6 out of 15 staff) in the Blackburn with Darwen CITNS team to 100% in the 0-19 South Ribble East team (19 staff).

• From January to August 2016 referral to treatment times for occupational therapy consistently missed the 92% standard averaging 73% in this time period.

• From January to August 2016 referral to treatment times for speech and language therapy  consistently missed the 92% standard averaging 89% in this time period.

Updated 11 September 2019

This service has not been inspected before. We rated it as good because:

• Staff had good access to training to support their roles. Managers had oversight on mandatory training levels. Staff had a good awareness of the need to protect patients from abuse and neglect and there were systems in place to support them. Premises and equipment were clean and well maintained. The service followed best practice guidance on the decontamination and sterilisation of used dental instruments. Staff had a good awareness of the incident reporting process. Incidents were investigated and where necessary the patient was fully informed, and an apology given in line with the duty of candour.
• The clinicians provided care and treatment tin line with current nationally recognised guidance. There was an effective use of skill mix within the service including dental therapists and dental nurses with extended duties. Staff worked with other healthcare professionals in the best interest of patients. Staff had a good understanding of the importance of obtaining and documenting consent and were fully aware of their responsibilities under the Mental Capacity Act 2005.
• Staff cared for patients with kindness and compassion. During the inspection we received feedback from 35 patients. They told us that staff were friendly, helpful calm, kind and patient. We witnessed positive interactions between staff and patients throughout the inspection. The service carried out the NHS Friends and Family Test. Between June 2018 and June 2019, the service received 2379 responses. Of these responses 99% of patients would either highly recommend or recommend the service to friends and family. Staff from one location were due to receive an award for obtaining 1435 responses between June 2018 and June 2019.
• The service took into account patients individual needs. All locations which we visited were fully accessible for wheelchair users and those with limited mobility. They had access to wheelchair tippers. There was access to translation services and arrangements for patients with sight and hearing loss. The service dealt with complaints promptly, positively and efficiently.
• There were clearly defined roles and responsibilities within the service supported by an effective management structure. Governance arrangements were well embedded and there were clear lines of accountability. Morale within the service was good and staff spoke proudly and passionately about the service which they provided. The service actively monitored and managed risk well. The service engaged well with staff, patients, external stakeholders and other healthcare professionals well in order to continually improve the service.

Updated 23 May 2018

Our rating of this service improved. We rated it as good because:

• Staff knew how to report incidents and these were discussed at monthly team meetings.
• The staffing levels had improved since the last inspection to between 90% and 100%. Staff followed a formalised flow chart of actions to be taken if there were instances of sickness.
• Infection control and prevention audits were regularly undertaken.
• Records we saw were comprehensive, patient centred and used recognised assessment tools for monitoring pain, nutrition, hydration and skin condition.
• The service participated in National Institute for Health and Care Excellence audits such as the use of waterlow scales and end of life care.
• The service continued to have input from pharmacists, a physiotherapist, occupational therapist, integrated therapy technician and speech therapy. With the introduction of the community frailty service staff ensured there was improved joint working and more timely access to their services.
• Staff had access to training and development and there were nurse links for tissue viability, end of life care, dementia, falls and infection control. Healthcare support workers were about to enrol on the associate practitioners course which would enable them to enhance their practical skills.
• Patients were very positive about the care they received and we saw patients were treated in a professional and caring manner.
• At the last inspection management of the risk register was found to be poor. We found the risk register was now up to date, reviewed monthly and actions taken where needed.
• Patient outcomes were collected and monitored using the national hip fracture audit and national Parkinson’s audit.
• There was good leadership at ward level and above. Staff spoke highly of their line managers and told us they felt listened to.

However:

• There were still two registered nurse vacancies to be filled. These were being advertised at the time of the inspection.
• At the last inspection some staff were unsure of their future due to a lack of direction and strategy for the service. We found the service had made inroads into developing their service and there remained six members of staff on six temporary contracts. Further work was needed to ensure these contracts were made substantive.

Updated 29 October 2015

We found that Lancashire Care Foundation NHS Trust was providing a high quality service regarding end of life care (EOL). It was delivered by passionate staff who gave patients and their families compassionate care were however there were areas for improvement in the effective domain.

Caseload numbers had continued to increase but shortages were addressed through additional hours by staff and the use of agency staff when required and patient needs were being met. The decreased skill mix of staff had been recognised and changes to work patterns were being discussed. Staff worked with hospices, hospitals, GPs and specialists for advice when needed. The hospice team provided specialist advice and support as requested, coordinated and planned care for patients at end of life in the community. The trust had also not appointed a board member with a specific lead role for end of life care to ensure executive scrutiny.

The trust had developed an EOL framework and an advanced care plan but these were still in draft form and yet to be embedded. The nursing staff were working with primary and secondary health care professionals to adopt nationally recognised best practice tools, including the gold standard framework, preferred place of care, the priorities for care for the dying person and advanced care planning to replace the Liverpool care pathway. It was evident the trust were trying hard to achieve partnership working despite the difficulties of different services being provided under different trusts. However, the timeline of this improvement was slow as this should have been implemented in July 2014.

Staff appraisals were completed however there were inconsistencies in staff supervision. Staff spoke positively about the support they were given by seniors and management within end of life care although staff were not aware of who the trust lead for end of life was.

A review of the data showed there was a shortfall in monitoring systems in place to ensure the trust delivered a good quality EOL service. It was from discussions with patients, relatives, staff and observations that highlighted the commitment and passion staff of all grades had to provide good end of life care. Staff involved patients and their relatives in their care where possible and treated them with kindness, respect, compassion and dignity.

Updated 11 September 2019

Our rating of this service improved. We rated it as good because:

• The service provided safe care. The ward environment was safe and clean. The ward had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
• Staff developed recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the ward. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They followed good practice with respect to young people’s competence and capacity to consent to or refuse treatment.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. Staff actively involved patients and families and carers in care decisions, where possible, including working together to produce an impressive wall display to remind patients of ten key rights when attending care programme approach meetings.
• The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

• While staff ensured that they were recording most of safeguards relating to seclusion, we found one example where staff had not recorded that parents or carers were informed of one seclusion episode.
• There were a small number of minor issues picked up in our clinic check including some stock medication exceeding suggested amounts and some unnecessary clutter. This was due to the recent change from two wards to one ward and staff were aware and working on these.
• While detention papers had been checked by the receiving nurse and scrutinised by an administrator, on three out of four relevant records, we did not find evidence of medical scrutiny to make sure the clinical grounds for detaining patients were made out.
• Staff were discussing patients’ religious needs with them but, in one record, these discussions were not fully reflected in the patient’s care plans. Care plans could provide more detailed information about patients’ education status and needs. The education provision was limited but this was beyond the full control of the trust.

Updated 11 January 2017

We rated Lancashire Care NHS Foundation Trust specialist community child and adolescent mental health services as good because:

• All parents and young people said staff were welcoming, caring and respectful and listened to them. They found the service helpful and described positive change that had occurred after contact with the service. Parents could easily contact staff and found the teams responsive to their needs.

• Governance structures were in place to monitor performance targets and risk. Key performance indicators were used to assess the effectiveness of the service offered to young people. Most teams met the trusts target of 18 weeks waiting time from referral to assessment. Issues affecting waiting times such as staff performance, sickness and vacancies were monitored and addressed promptly. 

• Staff employed by the service had good compliance with mandatory training, supervision and appraisals and had opportunities for specialist staff training and development. Child and adolescent mental health services had a range of suitably qualified staff who offered a choice of therapies to young people and their families.

• Staff had a clear understanding of the trusts safeguarding procedures. Safeguarding systems were in place to support staff in the safeguarding process and monitor safeguarding incidents across the trusts children and families network. Staff had a good understanding of issues of consent and Gillick competence in their work with young people.

• Staff had a good understanding of National Institute of Health and Care Excellence guidance and other national guidance. Nine evidence based care pathways had been developed and were in the process of being introduced across the service.

• Staff described effective communication and referrals between services, such as local schools, social workers, GPs and health visitors. Systems were in place to support young people transitioning to adult services. The effectiveness of these systems was subject to ongoing review.

• Information about how to complain was readily available to young people and their families. Complaints were dealt with promptly and monitored across the children’s and families network. Parents, young people and staff were aware of the independent advocacy service. Child friendly posters and the trusts website gave comprehensive advice on how to access independent advocacy services.

• Staff felt valued and supported by their colleagues and were aware of the senior management team within the trust.

However:

• Not all young people had an up to date current risk assessment present in their care records. This meant young people were at risk of receiving care that did not take into account identified risks.
• The service did not collate quality measures in relation to primary reason for referral making it difficult to assess condition specific waiting times in line with National Institute of Health and Care Excellence guidance.

Updated 11 January 2017

We rated community based services for people with a learning disability or autism as good because:

• Person-centred therapeutic interventions were being delivered to patients to support them to achieve improved independence and wellbeing.

• Interactions between staff and patients demonstrated personalised, collaborative, recovery-oriented care planning.

• Comprehensive risk assessments for patients were completed and reviewed and clear crisis plans were in place where patients were assessed as

• Staff had a good understanding of the principles and application of the Mental Capacity Act.

• Patients were protected and safeguarded from avoidable harm and incidents were appropriately reported.

• Patients’ individual care and treatment was planned and best practice guidance was implemented, ensuring outcomes were monitored and reviewed.

• Staff had knowledge and skills to deliver effective care and treatment and staff received support and supervision from their managers and peers.

• Patients and their carers were positive about the care and treatment they received and staff behaviours were responsive, respectful and caring. Staff involved patients and their carers in the care and treatment they received.

• Managers were able to provide information into the governance meetings and staff received regular feedback from these meetings. They were kept up to date about their team’s performance.

• The management and governance arrangements within the directorate were effective and teams were able to feed information about risk into the risk register.The trust had identified 38 items on their risk register in relation to learning disability and autism community services and these were being reviewed and monitored by the trust.

However;

• There were gaps in the mandatory/essential training that staff should have received and not all staff had received an appraisal.

• Commissioning arrangements meant that the staffing skill mix and provision of psychiatric cover across the trust was variable.

• Information about complaints, concerns and compliments was not adapted to meet the needs of some patients with a learning disability.

• An audit of antipsychotic prescribing in people with a learning disability identified that there was action required against standard three of a quality improvement programme-prescribing audit. There were no clear dates for the action plan implementation following the audit.

Updated 11 January 2017

We rated community based mental health services for older people as good because:

• There were safe lone working practices which were standardised across each of the localities. This promoted staff safety when visiting patients’ homes. Staff had manageable caseloads which helped to promote staff keeping patients safe. Referral information was coordinated and actioned quickly to minimise risk. Care plans had crisis care plans to inform patients and carers on what to do in crisis. Patients’ records contained comprehensive risk assessment and were stored securely on the electronic patient record.

• Staff were up-to-date with mandatory training. Staff had regular supervision and there was a new structured appraisal process which had quarterly review intervals. The new appraisal included key objectives and the trust’s visions and values.

• Teams had effective multidisciplinary working in the delivery of care and treatment. There was good interagency working with voluntary and third sector organisations. Staff took action to ensure that patients’ physical health needs were monitored and treated.

• The service had good systems to ensure the Mental Health Act was followed where patients were on a community treatment order. Staff had a good understanding of the Mental Health Act and Mental Capacity Act.

• There was a process in place so that patients on a community treatment order were informed about the availability of the independent mental health advocacy service and had their rights read to them.

• Patients spoke highly about the care they received from the staff within each of the older adult services. Patients told us about staff going the extra mile to support patients. Patients and those close to them were involved in the decisions around care and treatment.

• Access to services was coordinated through a single point of entry in each locality. There were some waiting lists but these were within the guidelines from the standard operating procedure of the service delivery timescales. This meant that teams were meeting the targets expected of them.

• There were low numbers of complaints and these were well managed. The service received 238 compliments within the last 12 months.

• Staff understood the trust’s vision and values. Teams were well-led by committed managers and staff felt respected and supported. Effective managerial operational meetings took place where incidents were discussed, team performance was reviewed and staffing and sickness in teams was considered. There was a commitment to service improvement to meet the needs of different patient groups.

However:

• The Fylde Coast rapid intervention and treatment team had changed their operational hours as a result of vacancies and safe staffing levels.

• The services were not routinely undertaking fire drill testing at each of the team localities.

• The executive management team were not fully visible and in some cases staff did not know who they were.

Updated 31 January 2024

Updated 23 May 2018

Our rating of this service stayed the same. We rated it as good because:

• Patients using the service told us that they were treated with dignity and respect and described the staff as caring and helpful. We observed that staff took time to communicate with patients in a respectful and compassionate manner and patients were empowered to become active participants in their care.

• All patients underwent a thorough assessment of need, care plans were holistic and recovery oriented and included physical health assessments, these were completed in collaboration with the patients, progress was regularly reviewed.

• Regular multidisciplinary meetings were held and attendance by outside agencies was encouraged. Families and carers were involved in this process where appropriate. Advocacy services were accessible and available to support patients.

• The hospital followed national guidelines on cleaning standards and monitoring procedures to provide and maintain a clean and appropriate environment to prevent and control healthcare associated infection. The wards were clean and tidy and there was an established cleaning regime. All clinic rooms were fully equipped. Emergency equipment was accessible to all and was maintained appropriately. Medicines were dispensed and stored securely and audits undertaken to ensure safe practice.

• The ward environments were subject to constraints in observation. These were effectively managed and risks mitigated with the use of observation and individual risk management planning. Regular environmental quality checks were conducted and patients were able to discuss and resolve environmental issues in community meetings.

• Electronic rostering was used to support staff management and staffing was reviewed regularly to ensure there was enough staff with the relevant skills to deliver safe patient care. Patients were supported by a skilled multidisciplinary team of staff which included nursing, psychiatric, psychological, occupational and dietetic support. Treatment practices were based on nationally recognised guidance.

• Any identified spiritual needs and cultural requirements were supported and families and carers groups were active in the service.

• Safeguarding processes were in place which reflected national guidance, and understood by all staff. There was a clear structure of reporting and responsibility for safeguarding adults and children. Any concerns relating to adult and child protection were communicated to the relevant protection agencies.

• Restrictive practices were reviewed regularly and patients were involved in the process. Regular patient surveys and community meetings informed improvements in patient care across the hospital.

• Staff were trained in and had a good understanding of the Mental Health Act and Mental Capacity Act. Staff followed local procedures and support was available from mental health act administrators. Patients were given information and support to ensure appropriate representation and aid understanding of their rights.

• There was an established governance structure with a defined hierarchy of reporting and decision making within the service. There were clear systems of accountability and senior managers were actively involved in the operational delivery of the service. There was a clear statement of visions and values, staff knew and understood the vision, values and strategic goals of the service.

• Staff we spoke with were positive about their roles and were positive about service development. Staff felt able to raise concerns without fear of victimisation and spoke positively about the organisation. They told us that they felt valued, had input into the service and were consulted and involved in service quality developments.

However:

• Most non-refrigerated medicines must be stored at less than 25°C to ensure they remain effective. Ambient room temperatures in two clinic rooms regularly exceeded this temperature.

• Key access to the seclusion room on some wards was limited and staff described some difficulty finding key holders to access these rooms.

Updated 22 July 2022

We carried out this unannounced, focused inspection as part of our national review of urgent and emergency care centres, to support improvement in patient experience and the quality of care received when accessing services and pathways across urgent and emergency care.

We inspected the mental health liaison services in the emergency departments based at the following locations, all part of the Lancashire and South Cumbria NHS Foundation Trust:

• Royal Lancaster Infirmary
• Furness General Hospital
• Blackpool Victoria Hospital
• Royal Preston Hospital

We looked at the impact of mental health liaison within an urgent emergency care centre, as well as any possible impact on patient safety. This was a focused inspection with emphasis on specific key lines of enquiry within the safe domain, the responsive domain and the well-led domain.

We did not rate this service at this inspection. The previous rating of inadequate remains.

We found:

• The service provided safe care. There were enough skilled and experienced nurses and doctors. However, the provider had carried out a safer staffing review that acknowledged the different staffing needs in the new model of mental health urgent assessment centres and were implementing the review recommendations.
• Staff assessed and managed risk well. They reviewed patients’ risk regularly and they responded appropriately when risk changed.
• Patients had access to a range of services to meet their needs. There were good relationships with other teams and external organisations to ensure needs were met.
• Leaders had the skills, knowledge and experience to perform their roles. They had a good understanding of the services they managed.
• Staff felt respected, supported and valued. Managers ensured staff received supervision, appraisal and training.

However:

• The standard operating procedure did not correspond with practice in relation to the clock starting for 12-hour breaches
• The rotas in use did not provide oversight of all shifts at each location so that the provider could understand whether they are meeting the safe staffing establishment.

What people who use the service say

We were unable to speak to people using the service at the time we inspected. However, we requested feedback from patient surveys carried out by the provider.

Comments were mainly positive, ranging between 96% and 100% at the locations we inspected.

They included:

‘Straight to the point and made welcome in a calm and friendly manner.’

‘I was very impressed by the kind, attentive and empathetic approach evidenced upon my arrival to Avondale. The staff had plenty of time to talk with me and give relevant support.’

‘It was my first appointment and I felt very nervous about it but upon meeting staff I instantly felt relaxed calm and at ease.’

‘First time receiving proper help and everything I needed to say was said and listened to.’

A carer commented ‘Patient feels hopeful after speaking to staff and has changed his life.’

Updated 29 October 2015

We have judged the service as requires improvement because:

• The systems in place to monitor and manage patient risk were not robust. Moss View had a ligature risk audit, which related to the HDRU only. The audit was of poor quality as it was not comprehensive, itemised or specific. A ligature risk audit identifies places to which patients might tie something to strangle themselves and plans actions to mitigate the risks to the patient. Staff were not alert to the ligature risks on the CRU as the ligature points had not been identified and there was no formal management plan in place.

• Insufficient staffing levels on HDRU had been identified and noted on the local risk register. Shifts were filled to the required staffing level by redeploying staff from the CRU to the HDRU and through the regular use of bank staff.

• The service did not meet the Department of Health guidance on same sex accommodation. On the HDRU, there was an adaptable area that could provide either additional female or male beds depending on ward composition. At the time of our visit this area was mixed gender having a female bedroom next to a male bedroom. Individual pods on the CRU had been mixed gender on occasions. We observed male and female patients freely accessed each other’s pods, the communal IT equipment was located in one of the female pods and there was no separate female lounge

• We found restrictive practices in place. All kitchen knives on the unit were locked away and patients on the CRU did not have a key to lock their rooms when leaving them. These practices were not based on individual patient risk assessments

• Compliance with clinical supervision and yearly appraisals for nursing staff was poor. This meant that nursing staff did not receive the appropriate support and professional development needed to carry out their duties effectively and managers were unable to review their staffs’ competency or assess the quality of staff performance.

• Local governance structures to support the delivery of care and to monitor quality assurance were not well established as there had been changes to the location and structure of the rehabilitation wards in the past year. Staff did not always feel supported in their roles.

However, the unit was clean and well maintained. Medical staff received regular supervision, ensuring that lines of communication and support were in place. Staff had good knowledge of safeguarding procedures and were confident in applying trust policy. Physical restraint was rarely used as staff were confident in the use of de-escalation techniques. Patients’ physical health needs were routinely monitored and acted upon appropriately. Multi-disciplinary team meetings and handovers allowed the exchange of professional opinion and suggestions for onward treatment. Psychological therapies were available. Patients who used the service said that staff engaged with them in a caring, kind and respectful manner. A strong therapeutic relationship between staff and patients was evident. Patients using the service were given opportunities to be involved in decisions about their care. Patients had access to complaint forms and community meetings to discuss their concerns.

Updated 28 July 2021

We carried out this unannounced focused inspection because we received information giving us concerns about the safety and quality of this service.

We inspected the four wards for older people with mental health problems based at the Harbour. We inspected this service at the Harbour because that was the location where concerns were raised. We did not inspect wards for older people with mental health problems at the Trust’s other locations. We inspected:

Austen ward – an 18-bed female advanced care ward

Bronte ward - a 15-bed female dementia ward

Dickens ward – an 18-bed male advanced care ward

Wordsworth ward– a 15-bed male dementia ward

We inspected the wards for older people with mental health problems core service in September 2017. Following that inspection the core service was rated as good in each domain and good overall.

At this inspection we reviewed the safe, caring and well-led domains in full. We also reviewed some of the key lines of enquiry in the effective domain.

Our rating of services went down. We rated them as requires improvement because:

• The service did not always have enough nursing staff to meet patients’ needs. Staffing pressures had been exacerbated by the impact of the COVID-19 pandemic. The trust had strategies in place to mitigate these risks. However, we found that escorted leave and ward activities did not always take place as planned. Patients did not always have regular one to one sessions with their named nurse. There were sometimes delays in meeting personal care needs.
• Staffing pressures meant that supervision and team meetings did not happen as regularly as scheduled. Not all staff had received appropriate specialised training.
• Staff morale was low. Staff told us they did not always feel respected, supported or valued. Staff morale was impacted by staffing pressures and the COVID-19 pandemic.

However:

• Staff generally assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
• Wards were clean, well equipped, well furnished, well maintained and fit for purpose.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients.

How we carried out the inspection

During the inspection we visited all four wards and observed how staff were caring for patients. We spoke with 21 staff, 11 patients and nine carers. We reviewed 19 care records and 22 prescription charts.

We spoke with four senior managers at the Harbour and looked at a range of policies, procedures and other documents relating to the running of the service. We attended two meetings related to staffing.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

We spoke with 11 patients and nine carers. Patients and carers we spoke with were generally positive about staff. They viewed staff as kind, considerate and caring. Carers told us that staff could sometimes be difficult to get hold off but that they took the time to discuss their loved ones care with them and involved them in decision making where appropriate.

Updated 31 January 2024

Updated 31 January 2024