Lancashire & South Cumbria 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

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment the rating has remained good.

This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

Staff assessed the physical and mental health of all patients on admission. They developed individual care plans which were reviewed regularly through multidisciplinary discussion and updated as needed. Staff provided a range of treatment and care for patients based on national guidance and best practice. The ward team included or had access to the full range of specialists required to meet the needs of patients on the ward. Staff from different disciplines worked together as a team to benefit patients. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these 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.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

We reviewed 25 care records during the assessment.

Staff completed a comprehensive mental health assessment of the patient in a timely manner at, or soon after, admission.

Staff assessed patients’ physical health needs in a timely manner after admission.

Staff generally developed care plans that met the needs identified during assessment. There were gaps in a small number of patient care records reviewed where identified physical health needs did not have a specific care plan to ensure that staff were aware of how to provide appropriate care and treatment, such as a patient who had sleep apnoea.

Care plans were personalised, holistic and recovery-orientated. The care records were individualised to the patients and there was evidence of staff engaging with the patients to ensure their voice was reflected within their care plans.

Staff updated care plans when necessary.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well

Staff provided a range of care and treatment interventions suitable for the patient group. The interventions were those recommended by, and were delivered in line with, guidance from the National Institute for Health and Care Excellence.

Staff ensured that patients had good access to physical healthcare, including access to specialists when needed. Staff monitoring patient’s physical observations and would escalate if they had any concerns. The service had on-site GP sessions available for patients. The service also had access to dentists and podiatrists.

Staff assessed and met patients’ needs for food and drink and for specialist nutrition and hydration as required. The service had an on-site speech and language therapist (SALT) that staff could access for support and advice where required.

Staff participated in clinical audit, benchmarking and quality improvement initiatives.

The team included or had access to the full range of specialists required to meet the needs of patients in the service.

Staff were experienced, qualified and had the right skills and knowledge to meet the needs of the patient group. Managers provided new starters with appropriate inductions. However, we were concerned temporary staff were not always effectively inducted onto wards.

Managers provided staff with supervision and appraisal of their work performance. In October 2025, the average supervision compliance rate across the 14 wards was 81%. Ward managers were monitored their supervision and appraisal compliance rates and could provide a narrative where they were not meeting their targets. Staff generally felt supported within their roles and by managers.

Managers ensured that staff had access to regular team meetings. The majority of wards had held monthly team meetings in the three months prior to the assessment.

Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. Managers ensured that staff received the necessary specialist training for their roles.

Managers dealt with poor staff performance promptly and effectively. Managers gave examples of actions they had taken to manage staff performance and how they had escalated this where required.

Mental Health Act

The average compliance rate for staff training in the Mental Health Act was 99% across the 14 wards.

Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles.

Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were.

The provider had relevant policies and procedures. Staff could access Mental Health Act policies and procedures and to the Code of Practice.

Patients had access to information about independent mental health advocacy.

Staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done it.

Staff stored copies of patients' detention papers and associated records correctly and so that they were available to all staff that needed access to them.

Staff did regular audits to ensure that the Mental Health Act was being applied correctly and there was evidence of learning from those audits.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff held regular and effective multidisciplinary meetings. Staff and managers reported positive relationships between the multidisciplinary team. Patients were invited to and involved with ward rounds.

Staff shared information about patients at handover meetings within the team. Ward managers undertook audits of handovers to ensure that they were taking place as expected.

The teams had effective working relationships with teams outside the organisation. Stakeholders gave positive feedback about how the service engaged and communicated with them.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff supported patients to live healthier lives. The service had access to the tobacco treatment dependency team who could provide advice and support in relation to smoking cessation. Staff received mandatory training in treating tobacco dependency with an average compliance rate of 90%.

Information was displayed in ward areas around healthier living, lifestyles and eating.

The ward managers noted that cooking was generally an important activity for patients on multiple wards. Managers described how staff would promote and provide advice to patients about cooking healthy meals or alternatives.

The unit had an on-site gym which patients could access. The unit had also utilised walking groups as a way of encouraging movement and activity for patients.

On Fairoak ward, there were quality improvement projects in progress to promote healthy living. The ward had provided patients with pedometers to track their steps, and staff were encouraging patients to set goals in relation to this. A gym space had also been created on the ward with a good range of equipment that patients could access. Patients spoke positively about these activities. There was also a piece of work around healthy bowel movements and promoting conversations and discussions about this.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Staff used recognised rating scales to assess and record severity and outcomes.

Staff used technology to support patients.

The service had introduced Dialog+, a patient led outcomes scale, as a therapeutic tool to improve communication and understanding between staff and patients. This tool enabled patients to rate their satisfaction around quality of life and needs for care within 11 areas.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff took all practical steps to enable patients to make their own decisions. Staff explained how they would ensure that patients had all appropriate information to inform their decision making and would be supported through this process.

For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. Ward managers gave examples of how patients who might have impaired mental capacity had been supported on their wards. 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.