Lancashire & South Cumbria NHS Foundation Trust

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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

This meant service leadership was exceptional and distinctive. Leaders and the service culture they created drove and improved high-quality, person-centred care.

This service scored 89 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 4. The evidence showed an exceptional standard. The service had a very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team.

The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. Prior to our inspection, the Trust had introduced their autism enhanced mental health wards project. Ribblemere Ward was chosen to be a pilot ward for this. In doing so, staff from the ward team had been involved in carrying out an environmental audit of the ward to assess its suitability for autistic people. The audit listed each of the ward area and made recommendations on how the ward could become a more of a sensory aware environment. In doing the work to identify where the team were on the autism enhanced pathway, the team reported that this identified that they were already doing a lot of the suggestions and felt this was encouraging, as part of this work the team also spoke to women who had already had an admission and took advice from them about what could have made their experience better then used this to inform future plans.

Staff could explain how they were working to deliver high quality care within the budgets available.

Quality Statement Score: 4

We scored the service as 4. The evidence showed an exceptional standard. The service had exceptionally inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They always did so with integrity, openness and honesty.

Leaders had the skills, knowledge and experience to perform their roles. There was an abundance of training available to staff both within the ward and the specialist community perinatal team in relation to perinatal care. This included autism in perinatal period and eating disorders, most of the staff had completed compassion focused therapy training, along with DBT skills training, Institute of Health Visiting infant mental health training and a lot of the team were also trained to deliver this training to colleagues. Parent infant practitioners completed baby massage training and baby bonding. Some were trained in video interactive guidance where they film the mum interacting with her baby and then take positive snippets and share them back with mum. The teams had also completed a course in specialist perinatal risk training. There was also some staff who were studying a Perinatal course at level 7 (master’s degree) at university. In addition, some of the managers had taken the opportunity to take part in the cultures of care leadership programme, this included different modules and also someone with lived experience leading some of the sessions. Leaders had also accessed the Trust and Kings Fund leadership training.

Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care.

Leaders were visible in the service and approachable for patients and staff. Managers were based on the ward and in the same office as community staff, and staff told us that they found their local leaders to be accessible.

Quality Statement Score: 3

3. We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Friends and family test results were overwhelmingly positive for all services we visited, with very few complaints in comparison.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements.

Patients and carers were involved in decision-making about changes to the service. Lived experience groups were used to consult with previous patients on the direction of the service. For example, the ward staff had met with a group of recently discharged patients to discuss a pathway for patients who were autistic and for patients with complex emotional needs. Patients sat on interview panels for any new staff via the Trusts own peer support team. The trust collated responses and information was shared with staff through email bulletins and at staff meetings about changes made in response to staff feedback.

Staff had access to a confidential Freedom to Speak Up process and all the staff we spoke with about this were aware of the system for raising concerns and said they would feel safe to do so with no concerns about any reprisals or detrimental impact on them.

Patients and staff could meet with members of the provider’s senior leadership team and governors to give feedback.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff we spoke to told us they were well supported by the trust in terms of their wellbeing and work life balance, where possible and in line with service need. They did not report any bullying or harassment. The trust was proactive at ensuring flexible working arrangements were in place, and managers made reasonable adjustments where needed. Lots of staff within the community teams at all levels worked flexibly and this was well supported.

We saw good examples of the teams making reasonable adjustments for staff who needed them, sometimes with managers supporting staff for months or even in one example over a year, to remain in work despite difficult circumstances.

Managers had access to appropriate human resource support for recruitment, performance management and occupational health support. Relevant policies and procedures were in place to support this. There are equality and diversity champions within the service.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

There was a clear framework of what must be discussed at ward, team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients.

Staff maintained and had access to the risk register at team or directorate level. Staff at each level could escalate concerns when required. Staff concerns matched those on the risk register.

The service had plans for emergencies – for example, adverse weather or a flu outbreak.

Where cost improvements were taking place, they did not compromise patient care.

The service used systems to collect data from wards and directorates that were not over-burdensome for frontline staff.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, worked well and helped to improve the quality of care.

Information governance systems included confidentiality of patient records.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care.

Information was in an accessible format, and was timely, accurate and identified areas for improvement.

Quality Statement Score: 4

We scored the service as 4. The evidence showed an exceptional standard. The service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always share information and learning with partners and collaborate for improvement.

Patients were supported to keep in touch with people involved in their care, for example, their care coordinator. External professionals, including care co-ordinators attended multi-disciplinary meetings.

Managers understood the importance of positive working relationships with external partners and worked closely with other services to improve and develop the service. Staff had good links with other teams in the trust, including the perinatal and adult community teams, midwives, specialist perinatal midwives, health visitors and safeguarding teams. The use of the outreach team as a link between ward and community services worked well and reduced admission and readmission rates due to enhanced support for admission vulnerable women and women who recently discharged. The service had recently carried out an evaluation of the effectiveness of the outreach team and this had positive results in both reducing admissions and preventing readmissions. This was reviewed using outcome measure scoring and admission data.

The teams had good links with Action on Postpartum Psychosis, a national network of people who have been affected by postpartum psychosis. They had people who visited the inpatient ward twice a week, conducted monthly meet ups in local cafes, they assisted with home visits alongside healthcare professionals, had 1-1 meetings with service users and their partners in the community, provided video call and telephone support and also offered partner peer support and grandparent peer support.

Quality Statement Score: 4

We scored the service as 4. The evidence showed an exceptional standard. The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The teams were all actively involved in quality improvement and innovation projects to constantly improve the services offered to women in the perinatal period. This included the mothers on the margins project, The aim of this research was to improve mental health care during pregnancy and postnatally for mothers at risk of losing custody of an infant.

The perinatal services also led and took part in a regular Northwest Regional Research Forum, which brought together academics, clinicians and those with lived experience to share emerging evidence-based projects and host collaboration.

As well as this, the three-specialist perinatal CMHTs had in the 18 months prior to our assessment, integrated into the family hubs in Lancashire and South Cumbria, running clinics as well as being available for collaboration, advice and support to other services such as health visitors and the dads support network. This joined up approached had enabled women and families to have a one stop approach of knowing where to go for support and multiple services being available in all areas of Lancashire and South Cumbria.

The three-specialist perinatal CMHTs and Outreach team had been shortlisted for a 2025 Nursing Times Award, for “Innovation in the Community”. This was due to the work they were doing to support mothers at risk of inpatient admission and increase their choices around admission.

The service had an expert by experience group that had been running for around 2 years. This was attended by the peer support workers for the Trust, alongside other 3rd sector Perinatal organisations. The group met to improve the service by ensuring that lived experience was involved in service delivery and change. The group had recently held their first listening event where six ex-patients attended to provide feedback from their experiences of the service.

The perinatal services received funding to meet the expectations of the NHS long term plan, to further their criteria to moderate perinatal mental illness, expanding from the prior criteria of severe and complex. In response to this, the community services had decided in May 2023 to implement a clinic-based model at one team (Pennine) in order for them to continue to see higher numbers of families in the community whilst supporting integration into the communities. Due to the large geography covered by the Pennine Team, various clinics were opened throughout the patch in order to meet people in a place that was local to them.

Wards participated in accreditation schemes relevant to the service and learned from them. Ribblemere Ward had taken part in a number of different accreditations. The main one being the Perinatal Quality Network (PQN) accreditation, this works with perinatal network colleagues to share best practice at a national level. To be accredited by the Network, there are approximately 264 standards the ward must achieve.

The specialist perinatal community mental health teams had applied for accreditation following a peer review on 15 February 2023. The accreditation review was held on 6 March 2024, and unfortunately the teams were not accredited at that visit, but managers told us that this was only due to a lack of Psychology access in one team at that time. This had now been resolved and the team hoped to achieve accreditation in the near future.

The inpatient ward was also accredited by the Baby Friendly Initiative (BFI) gold accreditation through UNICEF alongside additional Lancashire services with midwives, health visitors, infant feeding teams and family hubs in the area. Ribblemere was the only perinatal inpatient unit in the country to be part of this accreditation. The ward’s Lead Nursery Nurse was also a trainer for BFI and offered yearly BFI updates and audited staff yearly.