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

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

Some aspects of the service were not always safe. The service was in breach of legal regulations due to staffing at both Crisis Resolution Home Treatment (CRHT) teams.

However, staff were aware of safeguarding and reported concerns appropriately. Care plans and risk assessments were focused on patients and people who used their services.

Medicines were managed well and the service focused on physical health of people and patients.

Staff attended mandatory training which was suitable for their roles.

Managers held regular meetings to discuss staffing and staff worked flexibly across different locations. Staff understood how to protect people and patients from abuse.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety based on openness and honesty. Staff listened to concerns about safety, investigated and reported incidents. Lessons were learnt to continually identify and embed good practice.

The service provided guidance to staff on the Patient Safety Incident Response Framework (PSIRF) and staff received patient safety training as part of mandatory training requirements. PSIRF is the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. All staff had completed level 1 and level 2 patient safety training.

Mid Mersey Crisis Resolution Home Treatment (CRHT) team reported a death of a person in September 2024 that was subject to a police investigation. Managers said the patient safety incident investigation was undertaken and due to be discussed at the service incident safety panel in June 2025. There were no immediate concerns about the level of care provided by the service.

At the time of our inspection, 2 rapid reviews were in progress following 2 deaths of people who used CRHT services.

The service did not have any other serious incidents in the 12 months before our assessment.

Staff knew what incidents to report and how to report them and described how they used the service’s online incident reporting system.

Staff within CRHT teams reported 104 incidents in the last 3 months, the highest number related to self-harm, people who needed hospital admission or missed appointments.

Staff within health-based places of safety (HPBoS) suites reported 1 serious incident during the last 3 months. The service monitored the number of incidents and any use of rapid tranquilisation medication.

From January 2025, the Mental Health Triage and Response Team (MHTRT) were responsible for co-ordinating Mental Health Act Assessments (MHAA) and monitoring compliance of contact with an Approved Mental Health Professional (AMHP) within 1 hour of a patient's arrival at a HBPoS.

Service-wide incidents were analysed within a monthly patient safety report during their monthly executive safety review. Incidents were discussed at divisional level with clear evidence of themed analysis and learning outcomes.

Staff felt confident to report incidents and met regularly to discuss learning from them. First response hubs introduced a follow up procedure for people who had requested crisis support and been signposted to local organisations. Staff received feedback from incidents and were debriefed where appropriate. Patient safety alerts were sent to teams and colleagues across the service to share actions required after learning from incidents across all teams.

Staff received feedback from the investigation of incidents, both internal and external to the service. The patient safety team sent regular practice alerts to promote high standards of care during an incident investigation, so staff in other teams could learn from this. Staff described increased occurrences of joint reviews before discharge between crisis and community teams following an incident of a missed follow-up appointment where the patient presented at a local emergency department.

None of the services that we inspected received a prevention of future death report from the coroner’s office in the 12 months before our inspection. Where appropriate, a report is issued by the coroner to relevant organisations where a death has occurred, to take specific actions to prevent future deaths.

Staff understood the duty of candour. They were open, transparent and gave patients and families a full explanation if things went wrong. The service had an up to date and clear duty of candour policy. Senior clinicians were responsible for contacting people who used services and families were supported by liaison officers from the service.

In the 12 months leading up to our inspection, there were 13 incidents where duty of candour was applied. All incidents that met the duty of candour threshold were included in a monthly patient safety report to service executives and quality committee.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Staff in the health-based places of safety (HBPoS) reported that they could easily access approved mental health practitioners (AMHP) to ensure patients were assessed under the Mental Health Act in line with legislation. However, there were some delays in securing a full assessment team. Data provided by the service showed the average waiting time for a mental health assessment across their 6 HBPoS was just under 8 hours in March 2025. This is within the 24-hour period outlined in the Mental Health Act, which can be extended by a further 12 hours for assessment.

The service used a single referral contact procedure and closely monitored progress of all current patients who were waiting for a Mental Health Act Assessment (MHAA). Any potential 24-hour breaches were discussed at various safety meetings throughout each day and system wide calls with the local integrated care board.

On arrival at a HBPoS, staff received a full handover from the police using an agreed template that included monitoring of the patient whilst in custody and a risk assessment which included reason for detention, items found during search and any current medication.

Upon discharge from HBPoS locations, a notification was sent to the patient’s GP, and a leaflet was given to patients with information to third party organisations.

Staff followed the service policy for people that did not attend their appointments, including when staff were unable to access the person’s premises or the person had left prior to the appointment ending. The policy provided a framework for staff to follow in such circumstances and was based on a trauma informed approach to care and treatment.

We observed staff daily multidisciplinary meetings in first response and Crisis Resolution Home Treatment (CRHT) teams where essential safety and risk information was reviewed about people who used services and included risk escalation plans. We reviewed 10 records for people who used CRHT services. They were detailed with personalised risk assessments that were updated and reviewed appropriately.

The service worked with people to understand what being safe meant to them as well as partners on the best way to achieve this. The service concentrated on improving people’s lives while protecting their right to live independently. Staff looked for potential concerns such as bullying, harassment, abuse, discrimination and neglect.

At the time of our assessment, 100% of staff were compliant with safeguarding level 1 training, 95% had completed level 2 and 93% had completed their level 3 training.

Staff described how to raise a safeguarding concern and gave examples of when they had raised them. Online incidents were raised through an online report for review by the service’s safeguarding team. Since January 2025, 66 safeguarding referrals were made by CRHT teams and health-based places of safety (HBPoS) teams.

Staff told us they could access support from the service’s safeguarding team when they needed it. This team also provided staff with feedback on safeguarding incidents and alerts.

Staff gave an example of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff described how a patient in the health-based place of safety (HBPoS) was supported by the community learning disability team during a Mental Health Act Assessment (MHAA) following detention by police under Section 136 of the Mental Health Act. They provided specific easy read information, advised the assessment team of behaviours that would affect the patient and supported them home following discharge.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Staff told us there were positive working relationships with stakeholders such as the police and local authority teams to resolve potential safeguarding concerns.

Staff spoke of the importance of least restrictive practice and knew where to request support if this was being considered.

The service worked with people to understand and manage risks by thinking holistically so that care met their needs in a way that was safe and supportive and enabled them to do the things that mattered to them.

We looked at records of 10 people who used Crisis Resolution Home Treatment (CRHT) Teams and 16 patients who used health-based places of safety (HBPoS). Records consistently showed that people were involved in their treatment across both services. People, patients and carers across both services spoke positively about their treatment, felt fully involved and knew how to access support if they needed to.

Managers completed 2 monthly audits across both CRHT teams and first response hubs of safety plans and biopsychosocial assessments to measure quality of practice against the National Institute for Health and Care Excellence (NICE) guidelines and suicide prevention strategies. Their audit between January and March 2025 showed compliance between 81% in January 2025 to 99% in March 2025 with actions to improve compliance by July 2025.

Staff involved patients in care planning and risk assessment. All care plans we reviewed showed clear evidence of involvement with patients, people and carers. They were written in a way that the people who used services could understand.

Staff demonstrated understanding of the use of restraint or restrictive practices as a last resort. Conflict resolution was included in the service’s mandatory training matrix, with 100% of staff having completed the training at the time of our inspection.

Information received from the service between September 2024 and March 2025 confirmed there were 5 incidents of restraint or restrictive practice. Four incidents happened across the CRHT teams and one incident at the health-based places of safety (HBPoS).

The service detected and controlled potential risks in the care environment and made sure that the equipment, facilities and technology supported the delivery of safe care.

All of the service’s health-based places of safety (HBPoS) suites allowed staff to observe patient areas. There was closed-circuit television (CCTV) at all HBPoS suites.

The service completed environmental risk assessments for each HBPoS location. Potential ligature points were identified and mitigated against through staff observations.

The Mere Suite and all HBPoS locations we visited were spacious, allowing room for patients to move around and for safe use of physical interventions, when necessary.

Not all staff within Crisis Resolution Home Treatment (CRHT) teams had personal alarms or lone worker devices. However, staff told us there was a consistent welfare procedure for appointments and undertook joint visits for new people or for those with known risks.

Patients, carers and people who used services told us locations they attended to receive care and treatment were suitable and in a good state of repair.

Consultation rooms used to meet people who used services were secure, suitably furnished and had sufficient seating.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. Staff checked resuscitation equipment daily using an online system, which alerted managers by email if the check had not been carried out.

Staff maintained the confidentiality of information about patients. Staff were aware of the importance of this, explained how care records were secured, and computers were locked when not in use.

The service made sure staff received effective support, supervision and development and worked together effectively to provide safe care that met people’s individual needs. However, the service did not always make sure there were enough staff.

At the end of March 2025, there were 78.82 whole time equivalent (WTE) vacancies across all CRHT and first response hubs.

• Mid Mersey’s first response hub had the highest number of vacancies at 38.74 WTE with qualified staff at 27.74 WTE.
• Mid Mersey’s CRHT team had 21.29 WTE vacancies with qualified staff at 8.96 WTE.
• North Mersey CHRT team had 12.39 WTE vacancies with qualified staff at 4.35 WTE.
• North Mersey first response hub had 6.40 WTE vacancies with qualified staff at 4.35 WTE.

Since April 2024, the number of vacancies had fallen by over 50% at both first response hubs and increased slightly at both CRHT teams.

Staffing has been recognised by the service and is currently a high risk on their risk register. The service had several staffing meetings each day and recent recruitment has emphasised the need for staff to be flexible and mobilise to several locations, in accordance with demand. Managers told us they had undertaken targeted recruitment events during the last 12 months. Several staff had been recruited and were awaiting final checks to proceed with employment. Recent recruitment had been successful with an induction programme for new staff planned for June 2025.

Managers calculated the number and grade of nurses and healthcare assistants required. Twice daily meetings involved detailed staffing discussions with quick decisions to ensure that demand was met, however, data provided by the service confirmed that there were 594 unfilled shifts at North Mersey first response hub and 177 unfilled shifts at North Mersey CRHT between 13 January and 16 April 2025. During the same period, 279 shifts were filled by bank staff at North Mersey first response hub and 603 bank staff shifts were filled at Mid Mersey first response hub. No shifts were filled by agency staff.

Between March 2024 and April 2025, the staff turnover rate was below the service target of 11% in all teams except for North Mersey first response hub which had a turnover rate of 21.01%. Managers told us about improved staff retention methods such as an increased focus on wellbeing and improved teamworking, illustrated by improved staff survey results in 2024.

Managers met with staff to reflect on, learn from their practice and provide increased support. Overall compliance with supervision was 83%, with 68% at first response hub and 72% at Mid Mersey CRHT due to short term staff sickness. Managers informed us that all outstanding supervision meetings were concluded in April 2025.

Managers provided new staff with appropriate induction and ensured that all mandatory training was completed as soon as possible during their induction.

When bank staff were used, they already worked for the service and had received a service-wide induction.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading or shared any concerns with appropriate agencies promptly.

During our assessment, we reviewed clinic rooms, consultation rooms, reception and waiting areas.

We observed clinic and consultation rooms at the first response hubs and Crisis Resolution Home Treatment team (CRHT) to be clean with clean and appropriate equipment. Clean areas were highlighted with ‘I am clean’ stickers.

We reviewed cleaning records across all first response hubs and crisis locations; they were up to date and demonstrated that the clinical and appointment areas were cleaned regularly. We found the health-based places of safety (HBPoS) areas were clean.

We observed consistent staff adherence to infection control principles, including handwashing and ‘bare below the elbow’ guidance during appointments and staff handover meetings. Personal protective equipment (PPE) was available for staff to use across all locations. Staff described the importance of infection prevention, particularly during home visits.

The service made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. Staff involved people in planning, including when changes happened.

Staff followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) and did it in line with national guidance. Consultants and staff in Crisis Resolution Home Treatment (CRHT) teams worked collaboratively to ensure people who used services had good access to medicines. Medicines were regularly reviewed by the multi-disciplinary team.

Staff reviewed the effects of medication on patients’ physical health regularly and in line with NICE guidance. Mid Mersey CRHT had a dedicated pharmacy support with a strong focus on identifying people with complex prescriptions and changing their medication to reduce the risk of side effects. The service was exploring how to replicate this practice in other teams.

Care records of people who used services showed that medication compliance and any proposed changes were discussed with them. Medicines changes were promptly shared with patients’ GPs so that their prescribing records could be updated. Concerns could be escalated to a meeting each morning where cases were discussed, reviewed and actions put in place to ensure people remained safe with their care and treatment.

We found that patients had access to critical medicines when in the services health-based places of safety (HBPoS) to manage pre-existing medical conditions. People who used crisis services received normal medication prescriptions as the least restrictive option and ensured people were included in their treatment plan.

Managers completed audits of physical health for people who used crisis services. Between September 2024 and March 2025, North Mersey and Mid Mersey CRHT teams were 84% and 92% complaint against a 90% target.

Staff at all locations described the importance of physical health monitoring, especially for people who were prescribed mood stabilisers or antipsychotic medicines and referred to regular meetings to share best practice.