Lancashire & South Cumbria NHS Foundation Trust

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• 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

This means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this newly registered service. This key question has been rated Good.

This meant people were safe and protected from avoidable harm. All areas we visited were safe, clean well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There were 2 serious incidents reported across the service in the 12 months prior to our inspection. Due to the low number of serious incidents there were no themes or trends to draw out from the incident reports. Staff told us that when they reported incidents, they received feedback in several ways including via team meetings, email, and during supervision. We found that staff had a good understanding of the duty of candour and gave patients and their families an apology and an explanation when things did not go correctly. Debriefs were carried out and support was offered to staff following serious incidents and staff told us that they felt this was beneficial and felt supportive.

Staff were able to tell us about changes made because of learning from incidents. Examples of learning from incidents included more joined up working with AE services, reviewing the quality of referrals received from other services in more detail and staff also told us about more wider learning shared across the Trust from other services.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. 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.

The services’ referral and admission processes ensured that all essential information about the patient was received to determine if their needs could safely be met. We reviewed 20 patient records whilst on site and found that a thorough risk assessment was always completed. They detailed risks both to and from the patient which were clearly gathered at the point of admission into the service to ensure staff had an overview of the needs of the patient.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the services and post-discharge. We saw that the correct professionals were invited to attend meetings about the patient’s care on the ward and in the community, as well as being involved in their discharge plans.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were trained in adult and child safeguarding up to level 3, this included online and face-to-face training. Staff knew how to make a safeguarding alert and did so when appropriate. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. All staff had access to safeguarding supervision which was usually facilitated by a social worker. The Trust specialist safeguarding team were also available and well utilised by both the inpatient and the community teams. Staff were able to give good examples of what constituted a safeguarding incident and what action to take.

Staff followed safe procedures for children visiting the inpatient service.

On the inpatient unit, there was only one blanket restriction which was noted to be outside of the Trust agreed list of restrictions for inpatient wards. This was a rule that the main bathroom door was to be locked when not in use to maintain patient safety, and staff would be present either outside the door or inside with patients if they posed a risk whilst bathing. Staff used restraint only as a last resort.

Mental Capacity Act

Over 95% of staff had completed training in the Mental Capacity Act.

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles.

Patients on the ward were either informal or detained under the Mental Health Act.

The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it. Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards.

Staff took all practical steps to enable patients to make their own decisions. For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions. When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.

The service had arrangements to monitor adherence to the Mental Capacity Act.

Staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 20 care records, which included individual patient risk assessments and management plans, across the ward and community teams.

In the 12 months prior to our inspection restraint was used 13 times on Ribblemere ward, with 6 of these being in one month due to a particularly complex patient. Rapid tranquilisation was used on 5 occasions only and 4 of these were in the same month,

Staff involved patients in care planning and risk assessment. This was evident in the care plans we reviewed, participation by patients in their multi-disciplinary team meetings and patients being aware of the content of their care plan. Where appropriate and agreed by the patient, family and carers were also involved in the process.

The service used feedback to develop and shape the service. Feedback was taken from as many patients as possible through surveys, questionnaires, suggestion boxes, and during ward community meetings. Examples of this included feedback on activities that had been well received from patients continuing on, patients being involved in interviewing of new staff and a peer support worker initiative where former service users could give feedback on new initiatives or any concerns about care.

Staff ensured that patients could access advocacy.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff did regular risk assessments of the care environment. Within the community teams, patients did not routinely visit the offices where staff were based. It was preferred where possible, for patients to be seen in a less clinical setting, such as their own home. On the ward, regular risk assessments were carried out of the ward environment. Although the ward layout did not allow staff to observe all parts of ward, this was mitigated by the use of individualised patient observations and staff presence on the ward area. Staff had carried out a ligature risk assessment of the ward and mitigated risks through patient observation levels, staff knowledge of the risk’s individual patients presented and regular checks of the environment. The ward complied with guidance on eliminating mixed-sex accommodation as it was a female only ward.

On the inpatient ward, babies tended to remain in the mums room at night, unless there was a reason for them not to, Examples, of this included when lack of sleep was impacting on the mums mental health, and it would be care planned for the baby (or babies) to go into the nursery overnight. For some baby’s, mum would still attend the nursery at feeding times and to comfort the baby, for others the nursery nurses provided this care for short periods of time. This was all individually risk assessed based on the individual patient.

Staff on the ward had easy access to alarms and patients had easy access to nurse call systems. In the community teams, any rooms on trust premises were fitted with panic alarms and staff were able to position furniture in the rooms so that they could exit safely if required. Staff utilised the lone working policy to alert their colleagues as to where they were going on visits and let them know once they returned. Staff knew how to contact the office if they felt unsafe in a situation and colleagues would provide support. Staff would conduct visits in pairs if there were identified potential risks to them on a home visit and if the risk exceeded this, the patient would be invited onto Trust premises for their appointment.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Both the ward and the community teams were well staffed with vacancies in the community teams reducing over the 6 months prior to our inspection. The use of agency and bank staff was low across all services with peaks in use relating to short-term sickness. The sickness rate was generally low across all teams, however, the ‘Specialist Perinatal CMHT for Central/West Lancs’ was currently sitting at 8% but had been as high as 13% in May of 2025. We saw that this was reducing, and staff were being supported back to work.

Managers had calculated the number and grade of nurses and healthcare assistants required. The number of nurses and healthcare assistants matched this number on all shifts we reviewed. The ward manager could adjust staffing levels daily to take account of case mix. When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. However, due to the specialist nature of the services, staff who already worked in the service tended to pick up extra shifts so that continuity of care for patients was maintained.

When agency and bank nursing staff were used, those staff received an induction and were familiar with the ward. A qualified nurse was always on duty. Staffing levels allowed patients to have regular one-to-one time with their named nurse. Staff shortages rarely resulted in staff cancelling escorted leave or ward activities.

There were enough staff to carry out physical interventions (for example, observations, restraint and seclusion) safely and staff had been trained to do so.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency. The community teams had access to a consultant psychiatrist and junior doctors that could be accessed quickly.

Staff had received and were up to date with appropriate mandatory training. The training was appropriate for the patient group using the service.

Quality Statement Score: 3.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date. All ward areas were clean, had good furnishings and were well-maintained. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. Staff adhered to infection control principles, including handwashing.

The community teams did not see patients on site in their own offices, and therefore we did not need to consider this quality statement for those environments.

Quality Statement Score: 3.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff followed good practice in medicines management and did it in line with national guidance. Medicines including controlled drugs were safely stored. Patients, relatives or advocates were involved in discussions about the risks and benefits of prescribed medicines. Staff reviewed the effects of medication on patients’ physical health regularly and in line with National Institute for Health and Care Excellence (NICE) guidance. Where required, the appropriate authorisation for the administration of mental health medicines was in place.

Pharmacy support was embedded into ward and community teams supporting oversight for medicines governance. Pharmacists were involved in multidisciplinary team meetings and were available to give advice and support to patients when required.