• Organisation

Mersey Care NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Good read more about inspection ratings
Important: Services have been transferred to this provider from another provider

Latest inspection summary

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Overall inspection


Updated 14 April 2023

We carried out two announced and four unannounced inspections of six of the mental health and community health services provided by this trust, and one unannounced inspection of an adult social care location, as part of our continual checks on the safety and quality of healthcare services. We inspected Ashworth, the high secure hospital because this must be inspected every five years in order to inform the High Secure re-authorisation process, and the last inspection was in 2017 where it was rated good. We inspected acute wards and psychiatric intensive care units (PICU) and community inpatients because we had received information giving us concerns about the safety and quality of these wards. We inspected the forensic and secure wards and wards for people with a learning disability and/or autism because the service had changed significantly since the last inspection and to review outstanding breaches of regulation in the forensic services. We inspected community health services end of life care to review outstanding breaches of regulation. We inspected the adult social care location as it had not previously been inspected under adult social care methodology.

At the last inspection of the trust, we inspected some of the services under the heading of specialist services for people with a learning disability and/or autism. This core service does not exist as part of our current methodology, and those services are now included in the forensic and secure wards inspection.

In 2017, Wavertree Bungalow had been inspected as a hospital location. However, due to changes made by the trust to the registration of this service this was now an adult social care location. In line with our current methodology, the findings from this report will inform the judgements we make about how well-led this trust is, but the ratings will not be aggregated and therefore will not impact on the overall trust ratings. This report will be published separately.

We also inspected the well-led key question for the trust overall because the trust now delivered services formerly run by two different trusts, and to inform the re-authorisation of the High Secure Hospital.

We did not inspect the following core services, which have outstanding breaches of regulation, because we did not have current risk based concerns about these services at the time of inspection. As a result of this, the historical ratings have remained and have been used to determine the overall ratings for each key question and for the trust as a whole:

  • Community mental health services for working age adults
  • Community mental health services for people with a learning disability and/or autism
  • Community health services – adults
  • Community health services – walk-in centres

We undertook a focused inspection of the walk-in centre core service and mental health crisis core service in 2022, as part of a piece of work looking at urgent and emergency care across the system. These services were not rated at this inspection and no breaches of Regulation were issued.

We did not inspect the following core services, which have changed significantly since the last inspection as they were transferred from another provider to Mersey Care NHS Foundation Trust, because we did not have current risk based concerns about these services at the time of inspection. As a result of this, the historical ratings have remained and have been used to determine the overall ratings for each key question and for the trust as a whole:

  • Wards for older people with mental health problems
  • Mental health crisis services and health based places of safety
  • Community based mental health services for older people
  • Community mental health services for people with a learning disability or autism
  • Community health services for children, young people and families  
  • Specialist community services for children and young people
  • Community health – Sexual health services

We did not inspect the following core services that have no outstanding breaches of regulation:

  • Substance misuse services
  • Community dental services

We are monitoring the progress of improvements to these services and will re-inspect them as appropriate.

Our rating of the trust ​stayed the same​. We rated them as ​good​ because:

  • We rated caring as outstanding, responsive as good, and safe and effective as requires improvement. We rated the trust as outstanding in well-led.
  • At this inspection, we rated three of the trust’s mental health services as good, and one as requires improvement. We rated two of the trust’s community health services as good and none as requires improvement. We rated the adult social care location as requires improvement. In rating the trust, we took into account the ratings of other core services not inspected this time.
  • The trust had the leadership capacity and capability to deliver high quality, sustainable care. Succession planning was in place and leaders had the skills, knowledge and experience to perform their roles and demonstrated integrity in doing so. Leaders were visible and approachable and understood the actions needed to mitigate challenges to quality and sustainability.
  • The trust had a clear vision and set of values and a robust and a challenging and innovative strategy was in place with quality and sustainability as top priorities. Staff, patients, carers and external partners had the opportunity to contribute to discussions about the strategy and the leadership team regularly monitored and reviewed progress on delivering it.
  • The trust had planned services to take into account the needs of the local population. The trust engaged closely with the Cheshire and Mersey Integrated Care System and fully aligned its strategy to local plans in the wider health and social care economy. Plans were consistently implemented and had a positive impact on the quality and sustainability of services.
  • The trust’s culture was centred on the needs and experiences of people who used services. We were told about and observed staff caring for patients in a kind and compassionate manner. Through the acquisitions of other services, the trust had sought to embed areas of good practice in their own ways of working if it was better for patients and staff.
  • Staff were proud of the organisation as a place to work and spoke highly of the culture. There was a strong organisational commitment and effective action towards ensuring that there was equality and inclusion across the workforce. Staff had access to training, supervision and appraisals and there were opportunities for professional development.
  • The trust's steps towards a culture change, focusing on a just and restorative learning approach had seen a reduction in formal disciplinaries. The culture encouraged openness and honesty at all levels within the organisation and staff felt able to report concerns. The trust took appropriate learning and action as a result of concerns raised and sought to learn from incidents, deaths, complaints and the wider system.
  • The trust took a pro-active approach to managing staffing pressures and had a clear workforce plan in place. This included a focus on growing their own staff and the retention of existing staff, which saw trust turnover rates reducing at the time of inspection. The trust managed daily staffing levels dynamically to ensure patient safety.
  • There was effective accountability across the trust with systems in place to ensure the flow of information from ward to board and back again. Leaders were clear about their areas of responsibility and there was a visible and consistent approach to risk management and board assurance. Appropriate governance arrangements were in place in relation to Mental Health Act administration and compliance.
  • The trust had clear and effective systems in place to provide assurance and escalate risk when needed. Performance was managed through clear structures and processes. Financial performance of the trust had been consistently strong and there were no examples of financial pressures compromising care. The trust worked with the wider health and social care system to plan for adverse events.
  • The trust board received holistic information on service quality and sustainability. Leaders challenged and interrogated data and used performance measures to understand the challenges facing the trust at any given time. Systems that were in place to collect data were constantly being reviewed to identify how they could be improved. Submissions were made to external bodies as required and there had been no significant data or security breaches at the trust over the last 12 months.
  • The trust was a forward thinking and pro-active partner and leader in the wider health and social care system. The trust was actively engaged in collaborative work with external partners, such as involvement with sustainability and transformation plans. Feedback from commissioners was that the trust was an excellent systems partner, supporting other partners and responding to concerns in the wider health economy.
  • The trust took a leadership role in its health system to identify and proactively address challenges and meet the needs of the population. The trust had a lead role in the system response to the COVID-19 pandemic and continued to support partners with mutual aid.
  • The trust had a structured and systematic approach to engaging with people who used services, those close to them and their representatives. The trust had access to feedback from patients, carers and staff and were using this to make improvements. Patients, staff and carers were able to meet with members of the trust’s leadership team and governors to give feedback.
  • Quality improvement and innovation were central to the trust’s vision to strive for perfect care. Staff had training in improvement methodologies and used data to drive improvement. The trust had worked with local and national providers as well as staff teams to identify new technology and innovative practices.
  • Individual staff and teams received awards for improvements made and shared learning. External organisations had also recognised the trust’s improvement work. The trust was actively participating in clinical research studies and in national improvement and innovation projects


  • The trust was experiencing staffing pressures across most services as a result of high levels of absence and vacancies. This impacted on patient’s access to therapeutic activities and on staff wellbeing.
  • Care plans were not always individual to the needs of the patient.
  • The trust still provided dormitory accommodation which did not ensure the privacy and dignity of patients was protected. Some of the estates needed maintenance and repair. The environment at Wavertree Bungalow did not always meet the needs of people using the service.
  • Governance systems did not always operate effectively in the core services. Audits did not always identify all areas for improvement and there was a lack of capacity and robust governance around medicines management in some areas.
  • The trust was not always meeting its internal target in responding to patient complaints and the quality of investigations varied, although work was being done to improve this at the time of inspection. Some trust policy dates were overdue for review and some of the written Duty of Candour letters did not meet the requirements outlined in the trust policy.

How we carried out the inspection:

  • In the acute and psychiatric intensive care unit (PICU) inspection we inspected 16 out of 17 wards, we did not inspect Hartley Hospital Southport. At Clock View Hospital we inspected four wards, Morris, Newton, Alt and Dee; at Broadoak Hospital we inspected Albert, Brunswick and Harrington wards; at Hollins Park Hospital Warrington we inspected both Sheridan and Austen wards; at Halton Hospital we inspected Weaver and Bridge wards; at The Knowsley Resource Centre we inspected Grasmere and Coniston wards; at St Helens Hope and Recovery Centre we inspected Taylor and Iris wards. We also inspected Windsor House which was a standalone acute ward. Newton ward at Clock View was the only PICU.
  • In the forensics inspection we inspected ten wards and one individual placement. At Rowan View Hospital we inspected Astley ward, Eden ward, Rivington ward, Marbury ward and Delamere ward as an out of hours visit. At Rathbone Hospital we inspected Allerton ward. At Hollins Park Hospital we inspected Marlowe ward and Tennyson ward. At Whalley we inspected Maplewood 1 and Maplewood 2 and one individual placement at North Lodge.
  • In the high secure hospitals inspection, we inspected 11 of the 13 wards; Arnold, Blake, Carlyle, Dickens, Johnson, Lawrence, Macaulay, Newman, Owen, Ruskin and Turner ward.
  • In the inpatient wards for people with a learning disability we inspected the only ward; Byron ward.
  • In the community end of life care inspection, we inspected two of the three teams.
  • In the community inpatients inspection, we inspected all four wards at Longmoor House.
  • We inspected the only adult social care service provided by the trust; Wavertree Bungalow.
  • We spoke with senior leaders as part of the trust-wide well led inspection.
  • We spoke with 253 staff in face to face or virtual meetings including; health care assistants, nurses, doctors, allied health professionals, and managers.
  • We attended and observed several meetings and committees held by the trust.
  • We reviewed numerous records relating to the care and treatment of patients.
  • We reviewed a variety of documents relating to the management of the trust and the services it delivers.
  • We held seven focus groups including staff network groups, staff side and junior Doctors.
  • We reviewed a variety of information we already held about the trust.
  • We sought feedback from several of the trust’s stakeholders such as Healthwatch, NHS England and advocacy services.

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

During our core service inspections, we spoke with 145 patients and 32 carers and family members. Patients, family members and carers spoke positively about the services.

Patients told us staff treated them well and with kindness. Patients told us staff were responsive to their needs and they felt able to talk to staff.

Patients in the community end of life care services told us nurses were caring, compassionate, and often, the care exceeded their expectations. They knew they could contact the service any time of day or night and they would be responded to and felt as though staff took their time to listen to them.

Patients on Byron ward told us staff were nice and respectful and spoke about a range of activities that staff supported them to access.

Patients in the acute and PICU services told us they felt safe and that staff treated them well and were supportive and caring.

Patients in the community inpatient hospital told us that staff listened to their needs and would share humour with them, which helped.

Patients in the forensics service told us they felt safe and that staff treated them well. Patients said they rarely had their escorted leave or activities cancelled, even when the service was short staffed. They told us they felt involved in their care.

Patients in the high secure service told us they mostly had positive relationships with staff and described staff as kind, friendly and caring.

Carers at Wavertree Bungalow told us that staff were amazing and they felt their family member was safe at the service. Carers at Wavertree Bungalow told us they really trusted staff at the service and shared comments including ‘the service was a lifeline’ and ‘it was one of those places we couldn’t do without’. All families and carers we spoke with said they felt involved in their loved one’s care and that staff communicated well with them.  


Some patients on Byron ward told us they found the noise on the ward too loud and that lunch was boring.

Patients in the high secure hospital expressed their frustration of the impact of staffing pressures on access to on and off ward activities and delays in accessing personal care.

Community health services for adults

Requires improvement

Updated 5 April 2019

This is the first time we rated this service and we rated it as requires improvement. We rated it as requires improvement because:

  • The service did not always have the right number of staff although staff had the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse to provide the right care and treatment.
  • There was a lack of clinical supervision in some services and competency based training was not always carried out.
  • Some equipment necessary for carrying out treatments was not always available.
  • Controlled medications were not always destroyed and disposed of in line with Trust policy and procedures.
  • A number of Trust policies and procedures were out of date.
  • Some staff told us that there was a lack of visibility of senior and middle management.
  • Some staff told us that they were reluctant to speak up to the ‘freedom to speak up champions’ due to previous experiences.


  • The Trust planned and provided services in a way that met the needs of local people and worked well with external organisations.
  • The service primarily used electronic patient records. Patient records were easily accessible by staff working in all community teams. Staff could access records using electronic devices in patient home and on computers based in clinic areas.
  • Records were clear, legible and information collated was in chronological order.
  • Staff from different specialities worked together collaboratively to benefit patients and their families.
  • The service controlled infection risk well and infection rates were low.
  • The service managed incidents well. Staff recognised incidents and reported them appropriately. There was a positive culture around the reporting of incidents and lessons learnt were shared with the whole team.
  • The service provided care and treatment based on national guidance and evidence based care.
  • The service had a clear vision and strategy in place. The service knew what it wanted to achieve and workable plans to turn it into action.

Community health services for children, young people and families


Updated 5 April 2019

We have not previously inspected this service. We rated it as good because:

  • Services were found to be good for safe, effective, caring, responsive and well led.
  • The service had effective strategies for identifying, managing and reducing risk, learning and improving when things went wrong.
  • There were sufficient numbers of competent and experienced staff to reduce the risk of harm to patients.
  • The service used best practice guidance to inform the delivery of care and ensured treatment was based on evidence based practice.
  • Staff within the service demonstrated good levels of commitment to patient care and they adopted holistic patient and family centred care. Patients and families believed the care provided was good.
  • The service planned and delivered care based on the identified needs of the community it served, but also built the service around the individual needs of patients. Staff were proactive in their approach to establishing the individual needs of patients.
  • There was an exceptional family focused approach to care delivery and staff had extensive knowledge about their patients.
  • The service was well led by effective and enthusiastic managers, who were aware of risks to the service and were capable of tackling difficult issues head on with a view to service improvement.

Community dental services


Updated 5 April 2019

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

  • Staff were qualified and had the necessary skills to carry out their roles and provide safe treatment to patients.
  • Infection control processes followed nationally recognised guidance.
  • Premises and equipment were clean and well maintained.
  • Staff reported incidents and accidents, these were investigated and acted upon to reduce the chance of re-occurrence. Learning from incidents was disseminated to all staff in the service through the “Notification of Clinical Improvement” system
  • Staff were aware about issues relating to safeguarding and there were systems in place to refer children and vulnerable adults.
  • Staff provided care and treatment based in line with nationally recognised guidance.
  • There was an effective skill mix at the service to assist with the ever-increasing complexity of patients. Staff worked together as a team and with other healthcare professionals in the best interests of patients.
  • Staff understood the importance of obtaining and recording consent. They had a good understanding of their responsibilities under the Mental Capacity Act 2005.
  • Staff cared for patients with compassion. We observed staff treating patients with dignity and respect. Feedback from patients was positive. Patients commented staff were kind, helpful, friendly and caring.
  • The service considered patients’ individual needs. Reasonable adjustments were made to ensure patients could access dental care.
  • The service dealt with complaints promptly, positively and efficiently.
  • Leaders had the skills and ability to support high quality care. Staff told us that management were visible and approachable.
  • The team worked well together and supported each other.
  • There were systems and processes in place for identifying risks and planning to reduce them.
  • Staff engaged with patients, external stakeholders and other healthcare professionals to continually improve the service.


  • The service did not have a consistent procedure or protocol for the use of hoists to assist patients with mobility difficulties to access dental chairs.
  • Staff told us that they felt “a bit frazzled” because of staffing issues. Staff worked hard to ensure that high priority clinics were not cancelled.
  • The policy supporting the use of the “Notification of Clinical Improvement” system had not been updated since 2002.
  • “Notification of Clinical Improvements” were only sent to one individual. This would pose a problem if this member of staff was ever away for a long period of time.
  • Individual results of the X-ray audit were not disseminated or discussed with dentists.

Community mental health services with learning disabilities or autism


Updated 14 October 2015

We rated this core service as good because:

•The service had developed clear, evidence based clinical pathways to support effective assessment, treatment and management of clinical needs. The teams worked effectively and collaboratively with other services to ensure continuity and safety of care across teams, including involvement of external agencies. We found that there were inconsistencies between the localities we visited, in relation to caseload management and service delivery. This meant that people may have a different experience of care or outcome of treatment, depending on where they receive their care. However, the community learning disabilities teams worked hard to meet the varied demands on the service despite challenges they faced at times with limited resources.

•People who used the service were treated with kindness, respect and dignity. Individuals were positive about the way staff treated them and were involved in the planning of their care. Clinician`s kindness, expertise and skills within the teams were highly regarded by all carers and patients we spoke with. The staff we met ensure  the people who use the service at the centre of what they did.

•The service operated an open referral system and had capacity to respond in a timely manner. The teams were confident that they all worked within the assessment targets agreed by the trust, however the systems in place to monitor compliance with waiting and response times did not appear to accurately reflect this. The teams worked flexibly to meet individual`s needs and worked closely with a number of different agencies to meet their needs, promote community involvement and social inclusion.

•The trust had a system to identify and monitor quality and safety of the services they provided. However, there were concerns with accuracy of recording and quality of data to monitor compliance with waiting and response times. There were not effective systems in place to monitor referrals, waiting lists, unmet need and the potential impact of gaps in service provision. There was a clear system in place to report incidents. However, we were concerned about the lack of comprehensive investigation into a serious incident affecting a member of staff last year.

• The community learning disabilities service was undergoing a comprehensive review of service delivery, local team performance monitoring and management structures, as part of the service re-design.Some teams, for example, both of the Asperger`s teams, and the administrative teams, did not have a line manager. Meeting structures were not in place which would support effective oversight monitoring across the whole service, for example, there were no management meetings or administration meetings in place. Most staff were concerned that there could be reduced learning disability representation within the senior management team with the restructuring.

•We saw good examples of local leadership from the team managers we met. Staff told us that they felt well supported by their team managers and were able to raise concerns and contribute to service development. The service manager and modern matron showed a good understanding of the current challenges for this service and staff.

Community-based mental health services for older people


Updated 14 October 2015

We rated the community based services for older people as ‘Good' overall because:

  • People had their needs assessed, care planned and delivered in line with best practice.
  • Multi-disciplinary teams managed the referral process, assessments, on-going treatment and care. This included care navigators who support people with dementia.
  • Common assessments and pathways for post diagnostic support for people with dementia had been agreed across mental health, acute and specialist NHS trusts.
  • People who used services had timely access to care and treatment.
  • There were systems in place to triage referrals based on the individual needs of people who used the service. Services were planned and delivered to meet people’s needs in a person centred way, taking their cultural needs into account.
  • Each team was well led by committed managers.
  • Each team had team objectives which helped guide staff and teams.
  • Two out of three of the memory clinics were accredited as excellent, with the Royal College of Psychiatrists’ memory services network accreditation project.

We saw outstanding user involvement initiatives with significant service user involvement and community engagement, including by people with dementia. This was particular apparent in Central Liverpool. This included:

  • the work of the service user reference forum.
  • service users and staff working as partners to be involved in developing apps to assist their memory, reminiscence and daily functioning and working with businesses to make them 'dementia friendly'
  • partnership work with Everton Football Club.

People were exceptionally positive about the care they received.

However, there were vacancies within teams which meant that some staff had to manage caseloads greater than they usually would. Care navigators were managing large numbers of people. We did not see significant impact on patients from these; managers were looking to address these by recruiting staff and working with commissioners.

Some risk assessments for people using the service were over 12 months old. Lone working practices did not always fully ensure staff safety. Staff were not always proactive in following up on updates on safeguarding processes. There were minor issues with equipment in the clinic room at Central Liverpool older people’s CMHT

Mental health crisis services and health-based places of safety


Updated 14 October 2015

We rated the health based places of safety as good overall because:

  • There was evidence of good inter-agency working including shared forums for reviewing issues, strategic meetings, addressing continued service improvements and positive relationships within the operational services.
  • Joint protocols were in place across Merseyside police, Mersey Care NHS Trust, the acute hospital trusts, local authorities and ambulance services involved in the detention, assessment and conveyance of people detained under section 136 of the Mental Health Act.
  • Joint procedures included a 10 step pathway for all involved in the process of section 136 to follow. The police used a traffic light rating system to support joint decision about remaining at the assessment or leaving.
  • There was a designated health-based place of safety in the city for children under the age of 16 years.
  • There had been no detentions of anyone subject to section 136 to police cells within Merseyside in the previous 12 months.
  • There was a culture of continued development. This included the street car initiative and the development of a heath-based place of safety within adult mental health inpatient services. There was also the implementation of employing health care assistants within accident and emergency services to provide one to one support for people detained under section 136.


  • The section 136 room at Aintree University Hospital did not provide a safe and a suitable environment for the assessment of patients detained under section 136 of the Mental Health Act (MHA) 1983 and there was a privacy and dignity issue at the Royal Liverpool University Hospital as the toilet door had been removed for safety reasons.
  • There were some considerable waits for section 136 assessments to be concluded. The reason was not clearly recorded in all the instances.
  • All of the forms that we reviewed required multi-agency input to record each stage of the 10 step care pathway retained within the A&E departments were incomplete.

Long stay or rehabilitation mental health wards for working age adults


Updated 5 April 2019

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

  • The service had worked to implement improvement regarding problems noted in the previous inspection. Ligature assessments were completed and up to date. We saw that mixed sex accommodation guidelines were being followed. The units themselves were clean and well furnished, with furniture appropriate to a rehabilitation setting. Staffing figures showed that more staff had been employed, and that safe staffing levels were prioritised. Risk assessments were completed and updated regularly. The service followed the trust guidance regarding no force first, this being evidenced by the minimal use of restraint in the service. Medication management was audited and noted to be of a high standard during the inspection.
  • Care plans were holistic, personalised, and patient-centred with patient involvement. Physical health monitoring was on-going at the service, starting on admission, and related to individual patient needs. Psychology input was available at the service, with multi-disciplinary input that guided therapy. We attended a psychology group meeting, and saw good interaction and patient involvement. Supervision and appraisals were taking place at the service, and staff told us that input from such sessions was helpful. Staff were trained in the Mental Health Act and the Mental Capacity Act, and we saw that both Acts were being implemented within the service, with access to administrators and consideration in care records of patient rights.
  • Patients told us they were happy at the service, and felt safe. We were told that staff were kind, helpful, and always available. Carers spoke highly of the service, stating that their relatives’ difficulties had improved since being admitted. Patient experience survey results were very positive, with 100% approval for many of the aspects reviewed. The inspection team saw good interaction between staff and patients, and a willingness by staff to be courteous, respectful, and helpful during this interaction.
  • The service looked to discharge dates for patients from the first ward review, and worked towards meeting those dates. At the time of the inspection, there were no delayed discharges in the service. Delays to discharge were often not down to clinical problems, but due to external factors beyond the scope of the service. Patients could access bedrooms at any time and there was safe storage for valuable items in each room. There were many different activities available seven days a week, and patients were encouraged to take part. There was lots of information available to patients and carers regarding treatments, rights, smoking cessation, advocacy, and volunteer work for patients.
  • Leadership training was available to managers in the service, and staff told us they felt that management on each unit were approachable and considerate. The trust visions and values were apparent throughout the service: signs and posters giving information were on each unit, and staff told us they were aware of the values and tried to bring them to the ward environment. An electronic dashboard of information regarding performance was available to managers, outlining service performance, and managers used this information to take the service forward, improving the patient experience. The brain injury rehabilitation unit was due to accept accreditation to a national brain injury charity, after being assessed over a period of time.


  • Some care plans contained jargon, language that might confuse patients.

Wards for older people with mental health problems


Updated 5 April 2019

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

  • We rated all key questions as good.
  • Improvements in the clinical environment and medicine management had been made since our last inspection.
  • Medicines were now managed safely. Equipment was now cleaned and recorded. Clinic fridge temperatures were also now monitored. Environments had been suitably adapted to meet the needs of patients with dementia. There were enough rooms to accommodate activity and therapy sessions.
  • Compliance with supervision, appraisals and mandatory training had improved, including basic life support, immediate life support, moving and handling and dysphasia training. Staff were now appropriately trained and supported for their roles.
  • Risk assessments and care plans had been completed for all patients and reflected patients’ lives and interests. They were personalised, holistic and recovery-oriented. Staff had developed a tool to support patient and carer involvement. Families and carers were involved in care planning and discharge planning.
  • The food was of good quality and drinks and snacks could be accessed 24 hours a day. Cultural beliefs were accommodated, including special diets.
  • Staffing levels and skill mix on each ward were appropriate to meet the needs of patients.
  • The service was now notifying the Care Quality Commission of Deprivation of Liberty Safeguards authorisations for patients. Mental Health Act and Mental Capacity Act policies and procedures were followed by staff.
  • There were effective systems and processes in place to drive quality improvement and safety. Incidents were reported and acted upon. Complaints were managed well and information fed back to patients.
  • Managers had the necessary skills and resources to ensure patient care was of good quality.
  • Staff felt respected by senior managers and morale had improved. Staff treated patients, their families and carers with kindness, privacy, dignity, respect, compassion and support. There were good relationships between patients, staff and carers.


  • There was dormitory bedroom accommodation on three wards. Beds were separated by curtains. This impacted on patients’ privacy and dignity.

Substance misuse services


Updated 27 June 2017

We rated substance misuse services as good because:

  • All the services we visited were tidy and well maintained. The furniture was in good repair and the clinic areas were clean and well organised. Staff understood infection control procedures.
  • Staffing levels and skill mix were planned and reviewed to keep patients safe and meet their needs. There were effective procedures for escalating concerns about staffing levels. There were effective handovers to ensure staff were aware of the risks to patients.
  • There were clearly embedded systems, processes and standard operating procedures to keep patients safe. The staff knew how to look for signs of abuse and how to make a safeguarding alert if necessary. This meant that patients were protected from avoidable harm.
  • Managers encouraged openness and transparency about safety. Staff knew what to report and how to report it. They understood their responsibilities relating to the duty of candour.
  • In most cases, patients’ needs assessments included consideration of clinical needs, physical and mental health and wellbeing, and nutrition and hydration needs.
  • Staff planned care and treatment in line with current evidence-based guidance, standards, best practice and legislation. Links to best practice guidance were available on the trust’s website.
  • Patients were supported to make decisions and, where appropriate, their mental capacity was assessed and recorded.
  • Staff respected patients’ diverse needs. Patients were supported, treated with dignity and respect, and involved as partners in their care. There was a visible person centred culture.
  • Patients were involved and encouraged to be partners in their care and in making
  • decisions, with any support they need. Staff spent time talking to patients so that they understood their care, treatment and condition.
  • Staff took into account the needs of different groups so that they met patients’ needs.
  • Patients understood how to complain or raise a concern. Staff took complaints and concerns seriously. They listened and responded to in a timely way.
  • The service was transparent and open with stakeholders about performance. Information was used to support effective decision-making and drive improvement. Staff reported and reviewed information on patients’ experiences alongside other performance data.
  • Staff felt respected, valued and supported. They were committed to their roles and enjoyed working with the patient group. They described a strong and supportive team.
  • Managers supported staff to work in innovative ways. They encouraged staff to discuss issues and ideas for service development.


  • At the Windsor Clinic, the fire risk assessment was out of date and actions had not been completed.
  • Not all patients had a comprehensive risk management plan that staff reviewed regularly.
  • Care records were not always comprehensive and holistic. They did not always take account of patients’ views. Some were not recovery focused and were not reviewed regularly.
  • Systems for audit and review in relation to care records were not always effective.
  • Some care records did not contain individual plans for unexpected exit from treatment.

Community-based mental health services for adults of working age

Requires improvement

Updated 5 April 2019

Our rating of this service went down. We rated it as requires improvement because:

  • There were long wait times for patient access to psychological interventions.
  • Staff compliance rates for role-specific mandatory training were low.
  • The service was going through a migration of one electronic system to another. New staff could not easily access the previous electronic record system.
  • Park Lodge and Moss House were not accessible for wheelchair users and the disabled toilet at Moss House was not fit for purpose.


  • There were no waiting lists for assessment by the community mental health service.
  • Risk assessments and audits of the environment, including infection control, were done regularly and were up to date.
  • Patients had robust, person centred care and treatment plans including physical health assessments. They were involved in the decision making about their care and treatment.
  • Serious incidents were being reported and managers were able to feed into the trust risk register. The service had a variety of ways that risks, concerns, complaints and lessons learnt were being communicated to staff.
  • The service had robust multidisciplinary and interagency teamworking.
  • The service provided a variety of information regarding community events, treatments and care services available for patients, carers and families.
  • Staff were trained in and had a good understanding of the Mental Health Act and the Mental Capacity Act. The service had policies and procedures in place and staff had access to support.
  • There was good leadership and the service encouraged learning and continuous improvement ideas from staff, patients, families and carers.