Mersey Care NHS Foundation Trust

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

The service assessed peoples’ needs and ensured that these needs were met. People who used the service were involved in creating personalised and holistic care plans to meet assessed needs. The service provided treatment recommended in national guidance, including medication and psychological therapies. The service made use of outcome measures to monitor patients’ progress and inform clinical decisions. Teams had good relationships with other services, both within the trust and within the voluntary and community sector. Staff supported people to live healthier lives. Staff assessed peoples’ capacity to consent to treatment. People subject to CTOs received treatment in accordance with the Mental Health Act. We found no breaches of regulations in relation to this key question.

However, only 70% of people received an annual health check. This was slightly below the trust’s target of 75%.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We reviewed a sample of 21 care records during this inspection.

Staff completed a comprehensive mental health assessment of each person in a timely manner. All new referrals were assessed by a registered nurse and a doctor at a daily triage meeting. When referrals were accepted, staff were required to meet with the patient, conduct a meaningful assessment, record a baseline for the patient’s mental state and provide a clinical intervention. Assessments included a biopsychosocial inspection and a risk inspection. Staff completed these assessments within 28 days of the referral.

Staff assessed peoples’ physical health needs in a timely manner. When people presented as having complexities around physical health and medication, their first appointment took place with a doctor. Each service employed specialist nurses to carry out physical health checks. If someone required urgent treatment, staff contacted the emergency services or took the patient to hospital. Community mental health teams aimed to ensure that 75% of people received an annual physical health check. Compliance fell slightly below this target, with an average 70% of people receiving these check-ups. The trust has included the risks relating to non-compliance with this target on its risk register. Staff had sought to address this by offering to conduct these health checks in peoples’ homes.

Staff developed care plans that met the needs identified during assessments. Once the initial assessment was completed, a key worker would be allocated to the person. Key workers were professional staff registered with a regulatory body. The key worker was responsible for developing, implementing and updating the person’s care plan. They created care plans based on assessments.

Care plans were personalised, holistic and recovery-oriented. They consistently demonstrated the involvement of the person using the service. They included specific details about the person’s social circumstances, support networks and relapse indicators. As well as focusing on the person’s mental health, care plans covered the person’s physical health needs and concerns about substance misuse. Each person’s plans for their recovery was included in a ‘My goals’ care plan. Staff updated care plans when necessary.

Staff provided a suitable range of care and treatment interventions. The interventions were those recommended by, and were delivered in line with, guidance from the National Institute for Health and Care Excellence (NICE). These included medication and psychological therapies and activities, training and work opportunities intended to help people acquire living skills. Interventions were based on peoples’ specific needs. Some people received depot (long acting injectable) medication or health monitoring due to the risks of medication. These people were usually placed on the caseload of a consultant psychiatrist and seen for a clinical review every six months. Some people required more frequent interventions. For these people, the service offered different pathways for psychosis, bipolar disorder, depression, anxiety disorders, personality disorder and a specific pathway for people aged 18-25.Treatment on the psychosis pathway primarily involved prescribing antipsychotic medication and psychological therapies, along with group work on understanding psychosis. Psychological therapies included cognitive behavioural therapy, dialectical behavioural therapy, cognitive analytical therapy, behavioural family therapy and eye movement desensitisation and reprocessing.

Staff ensured that people had good access to physical healthcare, including access to specialists when needed. Most people using the service received regular physical health checks, conducted by either the mental health service or by their GP.

Staff participated in clinical audit, benchmarking and quality improvement initiatives. The services used a comprehensive set of outcomes measures that were regularly audited to measure performance and peoples’ progress. These included the patient reported outcomes measures, goal-based outcomes, recovering quality of life measures, health of the nation outcome scores and clinician rated outcome measures.

The teams included or had access to the full range of specialists required to meet peoples’ needs. Each service employed nurses, support workers, psychologists and doctors. Social workers, including approved mental health professionals, were employed by the local authority, but were fully embedded within the community mental health teams.

Managers ensured that staff had access to regular team meetings. Each team held a meeting for all staff each month. At this meeting, staff discussed education, training, learning from incidents, staffing, clinical supervision, feedback from people using the service, trust-wide developments, quality assurance and performance.

Managers ensured that staff received the necessary specialist training for their roles. In addition to mandatory training, training on the comprehensive inspection of at-risk mental health, family therapy training and level one training on psychological interventions were considered essential for all staff. Staff were also encouraged to complete training on dual diagnosis and motivational interviewing.

The number of people subject to Community Treatment Orders (CTOs) varied between the different teams. Each service typically had three or four patients subject to community treatment orders.

Staff received and kept up to date with training on the Mental Health Act and the Mental Health Act Code of Practice and could describe the Code of Practice guiding principles.

Staff had access to support and advice on implementing the Mental Health Act and its Code of Practice. For example, the Mental Health Law Administration Teams sent reminders to responsible clinicians and clinical teams when actions, such as renewals of CTOs, were due.

The service had clear, accessible, relevant and up-to-date policies and procedures that reflected all relevant legislation and the Mental Health Act Code of Practice. The trust’s Mental Health Act policy had been updated in April 2025 and was scheduled for review every three years.

People using the service had easy access to information about independent mental health advocacy from a local advocacy provider.

Staff explained to each person their rights under the Mental Health Act in a way that they could understand, repeated as necessary and recorded it clearly in peoples’ notes each time. When a person was subject to a CTO, a social worker, responsible clinician or their community psychiatric nurse ensured they were aware of the implications of the CTO and their rights to appeal to a tribunal.

For people subject to a CTO, staff completed all statutory records. These forms were uploaded to the electronic patient record, and the original copies were kept in the Mental Health Act administrator’s office.

Care plans clearly identified people subject to the Mental Health Act and identified the Section 117 aftercare services they needed. Section 117 aftercare provides free support and services to individuals who have been detained in hospital under specific sections of the Mental Health Act 1983 after they leave. Social workers reviewed the arrangements for people receiving aftercare services under Section 117 of the Mental Health Act and ensured that details were included in care plans.

Staff held regular and effective multidisciplinary meetings. Multidisciplinary team meetings were set up with the purpose of ensuring accurate diagnosis, treatment and clinical decisions. Each service held a multidisciplinary team meeting every week, all staff were invited to these meetings. During the multidisciplinary team meetings staff discussed clinical matters including safeguarding, people requiring a 72 hour or 7-day follow-up, people in hospital, people at risk, new referrals, caseload allocations and any concerns that staff may have had.

Staff shared information about people using the service at effective handover meetings within the team. Each team held a daily safety huddle to discuss and plan responses to emerging risks. Huddles were attended by a minimum of four staff. We observed four of these meetings during the inspection. The meetings were efficient and productive. Staff clearly knew the people using their service well. They were familiar with each person’s individual risks and personal circumstances. The teams worked collaboratively, with staff offering to help and support each other.

The teams had effective working relationships, including good handovers, with other relevant teams within the organisation. The services worked collaboratively with other teams within the trust to support people. This included perinatal services, a specialist personality disorder service, the crisis resolution and home treatment team and inpatient mental health services. Early intervention services worked with child adolescent mental health services with children and young people aged between 14 and 18.

The teams had effective working relationships with teams outside the organisation. As part of the transformation to a new model for community mental health services, Mersey Care had commissioned 9 voluntary and community sector organisations to support their work. These organisations provided employment support, facilitated recovery, improved social inclusion and identified unmet needs. Staff from these organisations attended multidisciplinary team meetings to discuss people they were supporting. All the services sought to encourage good relationships with peoples’ GPs. Shared care arrangements were agreed with GPs for people prescribed lithium or sodium valproate. These agreements meant that the GP conducted physical health checks for these people. Staff sent copies of all inspections to GPs. However, a programme of placing mental health nurses, employed by the trust, in GP practices had not become well established. Staff explained that it had been difficult to provide cover for these nurses when they were on leave. This meant the support they provided was not consistently available. They also found that GPs had wanted these nurses to carry out work outside their role.

The service had worked collaboratively with the police to create a protocol to support people in a crisis and people at risk who had disengaged with services.

Staff supported people to live healthier lives, for example, through participation in smoking cessation schemes, healthy eating advice, managing cardiovascular risks, screening for cancer, and dealing with issues relating to substance misuse. Staff explained that many patients lived in deprived areas and found it difficult to sustain a diet of healthy food. Some people had riskier lifestyles involving drugs, criminality and alcohol. The service sought to support people by working collaboratively with other agencies such as substance misuse services and children’s services within the local authorities.

The services arranged activities that helped promote a healthy lifestyle for people using the services. This included walking groups, activity groups, swimming groups and gym groups. The early intervention team at Baird House facilitated an allotment group.

Staff used recognised rating scales to assess and record severity and outcomes. For example, staff conducted a Patient Recorded Outcome Measures inspection at the start of their care and treatment. When using this measure, staff supported patients to assess their level of connectedness, hope, identity, meaning and empowerment. Some services also used assessments that focused on the people’s quality of life, care needs and satisfaction with treatment. These assessments were repeated to measure the patient’s progress. Staff used a system of goal-based outcomes (GBO) to develop a realistic, shared treatment plan.

Staff took all practical steps to enable patients to make their own decisions. People using the service consistently told us that staff talked to them in an open and honest manner about risks and decisions about care and treatment. People said they found this helpful in making decisions for themselves.

For people who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. Records showed that staff assessed peoples’ mental capacity at every appointment when there were concerns about this.

When people lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. Most often, decisions made in peoples’ best interests took the form of admissions to hospital under the Mental Health Act. All admissions were carried out in accordance with the guiding principles of the Mental Health Act Code of Practice, including the principle of least restriction and maximising independence.

Staff received and kept up to date with training on the Mental Capacity Act and could explain the key principles of the Act. Training on the Mental Capacity Act formed part of the trust’s mandatory training programme.

Staff gave people all possible support to make specific decisions for themselves before deciding that someone did not have the capacity to do so. People told us that staff spoke with them about risks and how to deal with situations they were finding difficult. They said this helped them to make decisions for themselves.

Staff assessed and recorded capacity to consent clearly each time someone needed to make an important decision. Care records showed that staff completed full assessments of peoples’ mental capacity. When there were concerns about someone’s mental capacity, staff assessed capacity at each appointment.