Background to this inspection
Updated
11 December 2019
Navigo Health and Social Care Community Interest Company is a non-profit making organisation providing all local mental health and associated services in North East Lincolnshire.
The population of North East Lincolnshire is approximately 170,000 and areas within the authority rank within the 10% most deprived areas of England.
Navigo is registered to provide the following:
- Transport services, triage and medical advice provided remotely
- Treatment of disease, disorder or injury
- Diagnostic and screening procedures
- Assessment or medical treatment for persons detained under Mental Health Act 1983.
It provides the following services:
- Acute wards and community services for adults of working age
- Older People inpatients and community services (including admiral nurses)
- Long stay rehabilitation services for adults of working age
- Crisis resolution and home treatment services
- Health based place of safety
- Eating disorder services
- Forensic community services
- Early intervention services
- Personality disorder community services
- Housing and rehabilitation
- Family therapy
- Volunteer opportunities
Updated
11 December 2019
Our rating of the provider stayed the same. We rated it as good because:
- We rated well-led at the provider level as good.
- Managers at all levels had the right skills and abilities to run a service providing high-quality sustainable care.
- Senior operational roles had business as well as operational roles and responsibilities. They demonstrated understanding of their areas of expertise.
- Navigo’s strategy was aligned with the local sustainability and transformational plans and integrated care partnerships. They regularly monitored their progress.
- Staff felt respected, supported and valued and were positive about working for the provider. This was evident from the core services reviews that we undertook and also the staff and service user focus groups.
- Staff and service users were treated with dignity and respect, at times offering support outside of their commissioned services.
- Navigo practiced value-based recruitment and service users were always involved in the recruitment process.
- Navigo recognised members’, staff and volunteers’ achievements. In June 2019 they held their first volunteers and members award ceremony and held regular staff award events.
- Navigo had a well embedded governance structure.
- The provider reported no never events since our last inspection.
- Safeguarding governance structures were current and formed part of the providers quality agenda.
- Navigo had centralised clinical dashboards that were available at all levels including to the board and to service areas; these were usually reported on quarterly to the board, however this data could be viewed daily.
- Navigo had the 12th highest response rate for the NHS staff survey of all NHS providers; they scored in the top 10% of all provider trusts in 11 of the 32 key areas.
- Navigo was involved in numerous national research projects.
- Navigo was involved in some innovative projects for staff, members and service users.
However:
- The long stay rehabilitation service we inspected was rated as requires improvement in both the safe and well led domain.
- In both core services we found that the provider did not have a policy on ligature risk or a comprehensive fire policy.
- Two bank staff member had not completed any mandatory training.
- Some medicine cards had gaps on them.
- In the rehabilitation service, not all incidents were reported and acted upon in a timely manner.
Wards for older people with mental health problems
Updated
28 August 2025
We inspected Navigo’s inpatient wards for older people with mental health problems on the 11 and 12 of November 2025. Navigo’s older persons wards are spread across two sites- The Princess Diana of Wales Hospital, where Konar Ward and Janine Smith Suite are based, and Tees House, a short distance away where Jane Lewington Suite is based. The older persons wards were last inspected in March 2023 and rated outstanding in safe and well-led. Tees house is currently unrated since Navigo completed the takeover in December 2022.
Konar Suite is a 13-bedroom ward for acute mental health admissions. The ward accepts admissions for patients with both organic (such as dementia) or functional (such as depression, schizophrenia or anxiety) illnesses. The Janine Smith Suite is a 10 bedroom ward for patients with complex mental health needs who require a longer stay. This unit was created to prevent out of area placements for the local population. The Jane Lewington Suite is a 15 bedroom ward based at Tees House for patients with a complex mental health presentation either through dementia, acquired or chronic neurological disorder alongside a severe and enduring mental health diagnosis, or a combination of these disorders. Tee’s House is also utilised by both Konar Ward and Janine Smith Suite patients for activities.
The wards provide inpatient treatment and facilitate discharge planning for patients to move into more appropriate care settings or return home. Patients can be admitted either informally or under the Mental Health Act (MHA). The wards had access to a range of professionals that formed a multi-disciplinary team (MDT) to meet the holistic needs of patients in their care.
We visited all three wards and found that the standard of care, the environments and documentation were excellent. We found there were enough staff to meet people’s individual needs, observed warm and meaningful engagement, activities and access to professionals. Staff were quick to respond to people’s needs and did so in a kind, caring and compassionate manner.
We did not identify any breaches of regulation during this inspection.
Mental Health Act and Mental Capacity Act Compliance Summary
Navigo had policies and guidance in place around the Mental Health Act (MHA) and the Mental Capacity Act (MCA). The policies were within date and had a scheduled review date. Staff we spoke with had a clear understanding of the difference between legislation and could identify the five key principles of the MCA. Managers had clear oversight of mandatory training of staff, ensuring staff were working within the regulations.
The ward had a Mental Capacity Act lead who could provide additional support and advice if needed. Leaders completed regular audits of MHA and MCA documentations to ensure patients were safe. Staff knew who their MHA officer was and how to raise any concerns or issues. Additional oversight was provided by the pharmacy team to ensure that people were prescribed medication safely and within regulations of legislation. Overall training compliance was 98.78%.
Specialist eating disorders service
Updated
15 February 2018
This was the first time we have inspected the eating disorders service.
We rated it as outstanding because:
Navigo Health and Social Care CIC provides a specialist eating disorder service for adults with complex eating disorders called Rharian Fields. The inpatient ward admits patients detained under the Mental Health Act 1983 and those admitted informally. It provides assessment, treatment and rehabilitation to patients who require a hospital admission due to their eating disorder. The service has an aftercare, outpatient provision, which patients who live locally can access once discharged from the ward into the community. There is also a day patient service, which sees patients in the community.
The ward has eight beds available for both men and women. The ward is situated on a site within the grounds of the county’s general hospital. Rharian Fields accepts privately funded patients as well as patients funded by the NHS across the United Kingdom.
At the time of our inspection, there were six patients allocated to the ward. All patients were female and there were no patients detained under the Mental Health Act. The outpatient provision was not currently required as there had been no local patients discharged recently. The community day patients’ service was located away from the inpatient ward at NAViGO House, and was not part of this inspection.
We have not inspected this service before and this inspection was unannounced.
To understand the experience of people who use services, we always ask the following five questions of every service and provider:
- Is it safe?
- Is it effective?
- Is it caring?
- Is it responsive to people’s needs?
- Is it well-led?
Before the inspection visit, we reviewed information that we held about these services, asked a range of other organisations for information and sought feedback from patients and carers at focus groups.
During the inspection visit, the inspection team:
- visited the ward and looked at the quality of the environment
- attended and observed a clinical review, handover, group therapy session and a lunchtime experience
- spoke with three patients who were using the service
- spoke with three carers of patients using the service
- spoke with the registered manager and the ward manager
- spoke with seven other staff members including the consultant, the psychologist, the dietitian, nurses and nursing assistants
- collected feedback from patients and carers using comment cards
- looked at five care records of patients
- looked at six prescription cards of patients
- carried out a specific check of the medication management
- looked at policies, procedures and other documents relating to the running of the service.
Community-based mental health services for older people
Updated
14 February 2017
We rated community-based mental health services for older people as good overall because:
-
Following our inspection in January 2016, we rated the service as good for effective, caring, responsive and well-led.
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During this most recent inspection, we found that the service had addressed the issues that had caused us to rate safe as requires improvement following the January 2016 inspection.
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The community-based mental health services for older people were now meeting Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014.
Long stay or rehabilitation mental health wards for working age adults
Updated
11 December 2019
We have not inspected this service before. We rated it as requires improvement because:
- Our findings from the key questions demonstrated that the service did not always provide safe care and did not always have effective governance processes to manage and mitigate risk sufficiently.
- Brocklesby Lodge could and had been easily accessed by patients from the health-based place of safety. Apart from recording this on the risk register, managers had not taken any action taken to try to prevent this from happening again.
- The service required further development to ensure it followed a recognised model for rehabilitation care. The service operated without a registered nurse on shift at night which was not in line with the essential requirement set by the Royal College of Psychiatrists and AIMS rehab quality network. There was no policy on self-medication which meant patients could not develop these skills.
- One out of the two medication cards had gaps where medicines had not been signed for on two days for a total of nine medicines.
- Despite managers being informed of incidents, they had not ensured that the incidents had reported promptly using incident reports. An incident where a patient gained access to Brocklesby Lodge from the health-based place of safety occurred in July which was not reported until after our inspection in August. We raised two medicines incidents with managers during our inspection and there was a three-day delay in completing an incident form to report these.
- One bank staff had not completed any training despite working for the provider for 14 months.
- Bank staff did not have access to the electronic patient record system. They relied on other staff to be able to read or input information.
- There was no policy on ligature risk reduction and no fire policy at the time of our inspection. However, the provider had written a draft fire policy and added management of ligature risks to their observation policy after the on-site inspection but submitted within the inspection window timeframes.
- One patient record contained a T2 which was completed on behalf of the Responsible Clinician. When we raised this, the Responsible Clinician rewrote the T2. However, they did not complete a capacity assessment to assess the patient’s capacity to consent to treatment to check that the patient continued to consent.
- Two rooms used to support treatment and care were not soundproof and this meant that patients’ privacy may not be upheld.
However:
- The ward was very clean and well maintained.
- Staff assessed and managed patient risks well including monitoring physical health. The use of restrictive interventions was low.
- Staff felt respected, supported and valued. They recognised the provider’s vision and values and could raise concerns without fear of retribution.
Acute wards for adults of working age and psychiatric intensive care units
Updated
11 December 2019
Our rating of this service stayed the same. We rated it as good because:
- The ward environments were clean. The wards had enough nurses and doctors. The use of restrictive practices was low, they managed medicines safely and followed good practice with respect to safeguarding.
- Staff developed holistic, 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 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.
- Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions
However:
- There was no policy on ligature risk reduction and no fire policy at the time of our inspection. However, the provider had written a draft fire policy and added management of ligature risks to their observation policy after the on-site inspection but submitted within the inspection window timeframes.
- There were no personal emergency evacuation plans in place for those that needed them.
- One bank staff did not have access to the electronic patient record system and had not completed any mandatory training.
Community-based mental health services for adults of working age
Updated
15 February 2018
Our rating of this service stayed the same. We rated it as good because:
- Clinic rooms were tidy and contained all the equipment required to carry out physical examinations. There were enough staff with the right qualifications and skills to care for patients who used the service. The service used a recognised risk assessment tool to assess and manage potential risks to patients and staff.
- Medication was stored in line with national guidance. Staff followed good practice in relation to medicines management. The provider reported serious incidents and carried out investigations where needed.
- The service provided care and treatment based on national guidance. There were a range of specialists to meet the needs of patients. Processes were in place for the support and management of staff performance. Staff had a good understanding of the Mental Health Act and the Mental Capacity Act.
- Staff treated patients with compassion. Patients were involved in decisions about their care and treatment. Patients were able to make advance decisions about their care and treatment. Patients and carers were encouraged to give feedback on services and the care they received.
- Services were meeting the national target for referral to triage/assessment and from assessment to treatment. Staff were flexible with appointment times. Both community health teams had suitable premises to provide care, support and treatment. Information was available to patients in different formats. Patients were given information on how to make a complaint. Learning from complaints was shared during team meetings.
- The provider had a robust recruitment process. The organisations values were included in annual performance reviews. Regular audits were carried out to ensure the safety and quality of services. Recommended changes were implemented following incidents. The provider had a risk register in place which was regularly reviewed.
- Staff always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. Computers and software were password protected to ensure confidentiality. The provider had a website which contained information about services provided, news and events.
However:
- Not all staff received regular supervision and appraisal. Some staff had not completed the provider’s mandatory training.
- The provider did not include Mental Health Act training in their mandatory training package.
- Patients who lacked capacity were not routinely referred to advocacy services