Mersey Care NHS Foundation Trust

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

There was a positive approach to safety. Risk assessments were person centred, proportionate and regularly reviewed. Staff met each day to discuss anyone who may be presenting a risk and took action to address these risks. When someone did not attend an appointment, staff were pro-active in contacting them. Staff reported incidents. Incidents were investigated and learning from these incidents was used to develop good practices. Caseloads were manageable. There was a strong understanding of safeguarding, and effective systems to ensure people were protected from abuse and neglect. The service employed sufficient permanent staff to meet peoples’ needs. The use of medicines was managed well. We found no breaches of regulations in relation to this key question.

However, whilst there were protocols for safe lone working, the trust did not provide staff with alarms to call for assistance when they were on home visits. Also, there was potential for improvements to be made to the environment at one of the services.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There had been four serious incidents reported through the NHS Strategic Executive Information System in the last 12 months. All these incidents related to patient deaths. The service had not received any prevention of future death reports from coroners in the last 12 months. There had been no never events. Never events are serious incidents that are entirely preventable.

All staff knew what incidents to report and how to report them. Staff recorded the details of incidents on an electronic incident reporting system. All incidents were reviewed by an incident monitoring team within the trust. Between January and March 2025, 301 incidents had been reported across all adult community mental health services within the trust. The most frequent types of incidents involved medication errors, self-harm, death, care pathways and service provision.

Staff understood the duty of candour. They were open and transparent and gave people and families a full explanation if and when things went wrong. When mistakes occurred, managers contacted the person using the service to offer apologies and to admit errors. In the event of the death of someone using the service, staff sought to engage with families and offer condolences. When errors were identified, staff sent a formal letter of apology and explanation, and signposted to other agencies that could provide support. Between April 2024 and April 2025, 15 incidents across adult community mental health services had met the threshold for duty of candour. The service had conducted an audit showing that compliance with the duty of candour policy was above 95%.

Staff received feedback from investigations of incidents, both internal and external to the service. All incident reports were read and signed off by a manager. Serious incidents received a rapid review by a manager within 48 hours. All rapid reviews were discussed at the divisional safety huddle. The process for a review involved an investigation, a written report, feedback to staff and implementation of recommended actions. The trust had adopted the NHS Patient Safety Incident Response Framework (PSIRF) for investigating serious incidents. Staff noted that fewer incidents were escalated to a formal investigation under this framework.

Staff met to discuss that feedback. Staff discussed incidents at multidisciplinary team meetings each week.

There was evidence that changes had been made as a result of feedback. For example, in December 2024, a person using the service committed a serious assault on a member of the public. The service conducted a thorough review. The review noted that staff had not requested details of the person’s criminal record from the police. This led to the service reviewing the criteria for requesting police records and raising awareness among staff of the need to do this.

Staff were debriefed and received support after a serious incident. Psychologists facilitated debriefing sessions for staff after incidents. Staff had access to individual support if they needed it. Staff gave examples of how they were supported, for example, after instances of aggression.

The service’s referral and admission processes ensured that all essential information about the person being referred was received to determine if their needs could safely be met. For example, when someone was discharged from an inpatient service, their care co-ordinator would attend their ward rounds at the hospital to ensure they knew the person and received all relevant information about them.

Staff involved all the necessary healthcare and social care services to ensure people had continuity of safe care, both within the service and post-discharge. As part of the transformation of community mental health programme, the services had discharged a considerable number of people over the last three years. For example, in one service, the number of people on the caseload had reduced from 700 to 400. People were discharged from the services when the agreed interventions had been completed and their mental health was stable. The decision to discharge someone from the service was made by the multidisciplinary team. Community mental health teams facilitated a discharge pathway that lasted for 12 weeks. This pathway involved discharge planning and ensuring that all referrals for further support had been completed. Staff assured people being discharged that they could return to the service if their conditions deteriorated. The service held monthly meetings with voluntary and community sector organisations to discuss people being referred to their services after discharge. The early intervention services provided a three-year programme of enhanced support. Staff began to support people to consider plans for discharge after the first 18 months of care and treatment. Some of these people were referred for continuing support from community mental health teams. Others were discharged to the care of their GP.

There were difficulties in finding places for people who needed admission to hospital, although staff said that if an urgent admission was required, this was usually arranged within 24 hours. Bed management meetings were held twice every day to agree which patients could be discharged from hospital and admit the people presenting the highest level of risk. If the service required a warrant to enter someone’s home to assess for admission under the Mental Health Act, this usually took three to four days.

Staff referred people to specialist services when necessary. For example, staff referred people for specialist inspections for autistic spectrum disorders when this was appropriate.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did so when appropriate. Between January and March 2025, staff had made 108 safeguarding referrals to local authorities. Staff were familiar with guidance on safeguarding that was available on the trust’s intranet. Staff said that if they had concerns relating to safeguarding, they would speak to their manager in the first instance.

Staff could give examples of how to protect people from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff were aware that many people using their services were vulnerable to abuse through domestic violence, coercive control or exploitation. Staff gave examples of when they had made safeguarding referrals, such as when someone presented at the service with bruises on their face and when someone may have been at risk of harming children. Staff reported specific concerns through the safeguarding process.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Safeguarding referrals were initially screened against the local authority threshold by social workers. These referrals were discussed in multidisciplinary team meetings and staff supervision. Team managers had oversight of safeguarding matters. The trust’s safeguarding team met with the local authority safeguarding team to investigate concerns and agree the most appropriate action to keep people safe. Staff referred people at risk of radicalisation to the Prevent team. This team aimed to ensure that people susceptible to radicalisation were offered appropriate interventions to protect against radicalising influences. Staff from the service attended Safeguarding Adults Boards, run by the local authorities.

Staff followed safe procedures for children visiting the service. Early intervention teams collaborated with child and adolescent mental health services to work with children and young people aged between 14 and 18. Staff usually met with these people at their home.

During the inspection, inspectors reviewed a sample of 21 risk assessments and risk management plans.

Staff completed risk assessments for each person at their initial appointment, and reviewed this regularly, including after any incident. Staff conducted a risk assessment of each person using the service after the initial triage. Staff used a recognised risk assessment tool and updated risk assessments if there were any significant changes to the person’s risks. Assessments were reviewed annually.

Staff could recognise when to develop and use crisis plans and advanced decisions according to people’s need. Each care record contained generic information, such as the telephone numbers of support services, along with specific information, such as who the person would like staff to contact if they became unwell.

Staff involved people in care planning and risk assessment. Records showed that care plans and risk assessments had been discussed with the person using the service. People told us that staff had discussed risks with them in an open and honest manner. They said they felt involved in the inspection and management of risk.

Staff responded promptly to any sudden deterioration in someone’s health. In each team, nurses were allocated to the duty desk. Calls to the service were triaged by secretaries and transferred to the duty desk if the caller appeared to be struggling or experiencing low mood. If the duty worker was concerned, they could arrange for the crisis team to visit the person. If the situation was less urgent, they would record the person’s details on the duty sheet and ensure they were discussed at the safety huddle the following day. Some people experiencing emotional dysregulation called the duty desk frequently. The service provided staff with additional training to support people in these situations. When staff identified high levels of risk, they could request support from the Specialist Pathway and Risk Consultation Service within the trust. This team gave specialist advice on assessing and managing risks.

Staff ensured that patients could access advocacy. People using the service were able to access advocacy services, provided by a voluntary and community sector organisation that supported people using mental health services across the trust and in other parts of the North-West.

Staff monitored people on waiting lists for changes in their level of risk and responded when risk increased. In most cases, the service triaged referrals within 24 hours and completed a risk inspection of patients accepted by the service. This meant that staff had a good understanding of the risks presented by people who were waiting for an intervention. In the 12 months before this inspection, there had been six safety incidents involving patients on a waiting list.

The trust had a suicide prevention strategy, known as the Zero Suicide Approach. Staff were familiar with this initiative. The strategy was based on developing four components of care covering engagement with people using services, safe and effective treatment, workforce competency, and learning and evaluation. As part of this strategy, the trust had introduced a protocol for people moving between services, risk training and safety plans.

Deaths within the services were reviewed at the trust’s mortality review group.

The service provided follow-up visits to people within 72 hours of discharge from hospital. The trust set a target for services to visit 80% of people within 72 hours of discharge. Between April 2024 and March 2025, the services had visited 90% of these people within the required time scale.

Staff did regular risk assessments of the care environment. Reception staff were aware when higher risk people were coming to the building. The electronic patient record systems included ‘flags’ to show when a person using the service presented a heightened risk. A business continuity plan was available in staff offices, providing information on what staff should do in an emergency.

All interview rooms and reception areas had alarms and staff were available to respond. Closed circuit television (CCTV) was installed at the entrance to services and in communal areas. Interview rooms were fitted with anti-barricade doors.

All areas were clean, well maintained, well-furnished and fit for purpose. Premises for all the service were clean and bright. Staff were friendly and welcoming. The service at Baird House had a second waiting area for people who may find the general waiting room too noisy and over stimulating. However, whilst interview rooms were clean, they did appear quite bare. Some staff said that Baird House could be difficult for people to get to as it was a long walk from the regular bus routes.

Staff followed personal safety protocols, including for lone working. Staff had measures in place to ensure their safety. For example, two staff visited people that presented a risk. Staff telephoned the duty desk or a receptionist when their visit ended. Staff could not recall any incidents of threats to staff safety. However, staff did not carry alarms to call for assistance when they were on home visits. Staff explained that they had found lone working devices difficult to use and had, therefore, stopped using them.

The services employed almost 300 staff in community mental health hubs across the trust. The largest was in South Sefton with 47 staff. The smallest was in Kirkby with 11 staff. Approximately one-third of these staff were employed as community practitioners. Early intervention services employed 123 staff across the trust. The turnover rate for early intervention services was 6.8%. The turnover rate was higher for community mental health teams, at 12.4%. Vacancy rates were low, at 7% for adult community mental health teams and 4% for early intervention teams.

Managers had calculated the number and grade of nurses and healthcare assistants required. Most staff said there were sufficient numbers of staff to meet peoples’ needs, although they recognised there had been challenges with staffing due to maternity leave and long-term sickness.

The number of people on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each person the time they needed. Managers allocated cases to staff. Managers monitored caseloads to ensure that cases were assigned fairly. Managers considered the complexity of cases when they reviewed allocations. Very few staff had a caseload above 20.

Staff had received and were up to date with appropriate mandatory training. The training was appropriate for the people using the service. The trust provided a mandatory programme of training that included courses on the Mental Health Act, safeguarding, basic life support and intermediate life support. All teams achieved a compliance rate above 85%. Staff were positive about the training opportunities available to them. For example, staff said they had completed a two-day training programme on formulation. Some staff were completing a post-graduate certificate in psychological interventions. Other in house training covered trauma, staying well plans, and working with people who have delusions or hear voices.

Managers provided new staff with appropriate induction. The responsibilities and requirements for staff induction were set out in the trust’s induction policy. Staff who had recently joined the service said their induction to the service, and their corporate induction to the trust, had been good.

Managers provided staff with supervision, meetings to discuss case management, to reflect on and learn from practice, and for personal support and professional development, along with appraisal of their work performance. Staff received clinical and managerial supervision every six to eight weeks. The service monitored compliance with this target each month. Overall compliance had been above 85% in all of the last 11 months. Staff discussed specific people using the service in clinical supervision.

Managers dealt with poor staff performance promptly and effectively. The trust had introduced a ‘just culture’ approach to managing staff performance and patient safety incidents. Managers were familiar with the four tests involved in this approach. Managers provided support to staff when poor performance was identified. If this support did not address the concerns, performance was monitored through a competency pathway that could lead to formal action against the employee.

All areas of the services were clean, had good furnishings and were well-maintained.

Cleaning records were up to date and demonstrated that the premises were cleaned regularly. All areas of the services were clean. Cleaning records were signed and up to date.

Staff adhered to infection control principles, including handwashing. The requirements for infection prevention and control were set out in the trust’s policy. The policy included hand washing instructions that were displayed in all toilets.

The service had systems and processes in place to safely support people with their medicines in the community. Patients’ medicines were regularly reviewed, and their physical health was assessed when mood stabilisers or antipsychotics were prescribed. One patient told us how the team had worked well with other specialist teams to manage their medicines alongside their changing physical health needs. Another said that they were always encouraged to share concerns about medicines so they could adjust them as needed. The trust scored in the top 20% of trusts for discussing the purpose, benefits, and side-effect of medicines with patients. The trust performed less well in discussing how to stop medicines safely with a score of 5.4/10. This was identified as an area for improvement (NHS community mental health survey 2024).

Staff provided practical medicines support and advice. One person described how staff had helped them to get a supply of their medicines when they had struggled to have their prescription filled due to a national shortage of their medicine.

Summary care records was used to confirm people’s current medicines on transfer to the team and clinic letters were sent electronically to GPs. Where patients had a community treatment order (CTO) that referenced medicines, copies were kept in the patients’ electronic record. The trust’s medicine management team worked collaboratively with GPs and primary care network pharmacists to support uptake of ‘shared care.’ Shared Care arrangements enabled patients to access their medicines closer to home and helped to ensure relevant ongoing monitoring takes place.

A dedicated team provided good capacity for supporting clozapine community titration with clear protocols for sharing information with the requesting consultant and CMHT. Peoples’ GPs were informed when clozapine was prescribed, and the trust had completed a baseline audit to measure compliance with local guidance.

Over 90% of staff handling medicines completed the trust’s medicines management training and an appropriate governance framework was in place to support non-medical prescribing. Controlled stationery and depot cards were managed securely. CMHTs showed good compliance with the trusts quarterly safe and secure handling of medicines audit (Average 95% Q4 2024/25). Should any shortfalls arise, action plans were in place, overseen by the medicine management team.

Staff recorded risks specifically related to medicines on a dedicated risk register. This register contained three entries relating to the oversight of prescribing and potential shortages of medicines.