Lancashire & South Cumbria 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

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

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

This meant people were safe and protected from avoidable harm.

All wards were generally safe and clean. 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 66 (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. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There had been 4 serious incidents at the service in the 12 months prior to the assessment. These were across 4 different wards with the last occurring in April 2025.

Staff were aware of the incidents including actions and learning that had been taken following these incidents.

As a result of some of these serious incidents the trust had commissioned a peer-led security review that was undertaken in March 2025. The review had identified recommendations of actions that the trust could take to make improvements to the service, along with highlighting areas of good practice. The trust had accepted the recommendations and had created an action plan to monitor their progress with embedding and completing these, which was still ongoing at the time of the assessment.

All staff knew what incidents to report and how to report them. Staff were aware of processes in relation to incidents and could give examples of reporting incidents. Managers were confident that staff reported incidents appropriately.

Staff received feedback from investigation of incidents. Each ward held monthly team meetings in which incidents and learning were considered and discussed.

Staff were debriefed and received support after a serious incident.

Staff understood the duty of candour. They were open and transparent, and gave patients and families a full explanation if and when things went wrong. Managers were aware of their responsibilities in relation to the duty of candour and could give examples of incidents that had met the formal threshold and how they had taken action as a result.

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 service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. Patient records indicated that staff assessed and considered patient’s needs from the time of admission.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. We spoke to patients who felt involved and informed about future plans for them within the service and in relation to potential discharge.

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 safeguarding, knew how to make a safeguarding alert, and did so when appropriate. There were 2 mandatory training courses for safeguarding which were level 2 and level 3 dependent on staff roles and responsibilities held. The average compliance rates for the 2 courses were 84.93% and 86.74% respectively.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

The service had made 12 safeguarding alerts to the Local Authority in the 12 months prior to the assessment. These were across 6 wards with 6 of the alerts being made by Langden ward.

The service had a safeguarding lead. Staff and managers were aware of who the safeguarding lead was and how to contact them. Managers gave examples of safeguarding concerns that had been discussed with the safeguarding lead and the advice given.

Staff followed safe procedures for children visiting the service. The unit had a family room which would be utilised for any on-site visits with children present. The service had a process for ensuring that any visits were appropriate and managed safely.

The service had an agreed list of restricted practices and items for the Guild Lodge site, based on the different levels of security across the site. The trust also had some additional temporary blanket restrictions on two wards based on specific risks for those wards which the trust reviewed regularly. The trust undertook searches in response to suspicion of a patient being in possession of restricted or prohibited items, along with searches taking place on a routine or random basis. Access to a restricted item had been a factor in a serious incident on the unit in December 2024, along with a further serious incident with potential missed opportunities for additional room searches. These factors had been considered as part of the external peer-led review of the security processes on the unit. The review had made recommendations in relation to searches across the unit which the trust had accepted and were embedding.

Mental Capacity Act

99% of staff had had training in the Mental Capacity Act. Staff also had access to additional training in the Mental Capacity Act.

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

The trust 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.

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 25 patient records during the assessment. Staff generally involved patients in their care planning and risk assessments which was evidenced within the patient records reviewed.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. Staff and managers gave examples of how they had supported patients to understand their care and treatment.

In the 6 months prior to the assessment, physical restraint had been used 168 times within the service with 62% of these incidences occurring on one ward, Elmridge. The next highest ward was Fellside East with 17% of the restraint incidents occurring on that ward.

For the same time period, the service had 34 uses of seclusion. Elmridge ward again had the highest use of seclusion with 10 of the 34 uses occurring from that ward.

There were 142 uses of rapid tranquilisation during this period, with 124 being on Elmridge. The use of rapid tranquilisation had significantly decreased in the 3 months prior to the assessment, reducing from an average of 44 in May to July 2025, to an average of 4 in August to October 2025.

The trust noted that a specific patient on Elmridge ward had resulted in a peak of activity and made the ward a significant outlier in this data. This patient had subsequently been transferred out of secure services to ensure their care needs were met.

Staff enabled patients to give feedback on the service they received. All wards held community meetings, although these had not occurred as frequently as expected on a couple of the wards.

Staff ensured that patients could access advocacy services.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The wards were a mixture of wards with en-suite bathrooms and wards which had shared toilet and bathroom facilities. The shared toilets and showers were generally quite tired in places and required some updating, in particular on Calder ward which had significantly discoloured toilets and on Fairoak ward where the flooring was worn and marked in places.

Staff did regular risk assessments of the care environment. Each ward had a ligature audit that had been completed within the 12 months prior to the assessment. The trust reviewed these audits on an annual basis. Where ligature points were identified, actions were in place to mitigate the risks of these.

The trust had removed free-standing bins from patient areas following a serious incident on the unit. However, the implementation of this was inconsistent on the wards. During our tours of the wards, we observed that small bins were still present in unlocked patient areas. These inconsistencies against what the trust had decided to implement were escalated to senior managers and the trust. The trust advised that they were sourcing a replacement that would mitigate the risks identified and these were due to be installed by the end of March 2026.

Ward layouts did not always allow staff to observe all parts of the wards. Managers and staff described how these risks were managed, such as through individual patient observations.

The wards complied with guidance on eliminating mixed-sex accommodation. All wards were single sex.

The wards were generally clean and tidy.

Staff had easy access to alarms and patients had access to nurse call systems.

The unit had multiple seclusion rooms which allowed clear observation and had toilet facilities and a clock. The inside of the door on Calder ward was scratched and graffitied. This was escalated during the tour of the ward and the ward manager confirmed action would be taken to address it. The seclusion room on Greenside was decommissioned pending some repairs being made but was expected to be re-opened within a week.

Clinic rooms were generally fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. Staff were not always completing the clinic room cleaning records as required and one ward, Dutton, we identified out of date items and equipment that staff had not identified or removed. Staff were not always recording and labelling the dates that liquids and bottles were opened.

The service made sure there were enough qualified, skilled and experienced staff who received effective supervision. However, the service did not have a clear and consistent process for completing local ward inductions for temporary staff that were working on the ward for the first time or who might not have worked on the ward for some time.

The wards generally had low vacancy levels. The majority of vacant posts were healthcare assistant posts.

The average staff sickness levels for the 12 months prior to the assessment across the 14 wards was 10.2%. Sickness levels on Forest Beck ward were the highest at 21.8% with the lowest levels on Whinfell ward at 4.5%. The trust had developed a programme of work to address the challenges of sickness absence and to support staff to stay well in work and feel supported to return to work. The trust had an aim to deliver a 15% overall reduction in staff absence by March 2026.

The average staff turnover rate for the 12 months prior to the assessment across the 14 wards was 10.5%. Turnover rates varied significantly across the wards, with the highest rate being Whinfell ward at 31.2% and the lowest being Bleasdale ward at 2.9%.

Ward managers 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. The service had not used any agency staff in the 3 months prior to the assessment.

The trust provided data on shifts filled and unfilled by bank and agency staff for the 3 months prior to the assessment. The trust reported that 500 shifts were unfilled during this period of a total of 16552 shifts across the 14 wards. This was 3% of shifts that were not filled by bank or agency staff. 4037 shifts were filled by bank staff during this same period, which was 25% of all filled shifts. Approximately 40% of bank shifts were worked by substantive staff working additional duties, and 60% by bank only staff. All remaining shifts were filled by substantive staff.

When using bank or temporary staff, the service did not have a clear and consistent process for completing local ward inductions for temporary staff that were working on the ward for the first time or who might not have worked on the ward for some time. Managers reported that generally staff would be shown around the ward by another member of staff but that checklists were not routinely used to ensure that staff were informed of all essential information for that ward. It was not clear how managers were assured that any temporary staff, particularly where they might be asked to work on different wards, would be appropriately informed of individual ward processes or how to manage emergency situations. Staff were provided with a site induction including keys and personal alarms, along with receiving a trust induction. The trust confirmed that a ward induction checklist was available within the welcome policy for temporary staff. Following the on-site assessment, the trust sent guidance to all ward managers to ensure the checklist was in place. The trust was considering additional actions to monitor the usage of the checklist and to assist ward managers with their oversight of this.

A qualified nurse was present in communal areas of the wards at all times. Staffing levels allowed patients to have regular one-to-one time with their named nurse. There were enough staff to carry out physical interventions safely and staff had been trained to do so.

Patients raised concerns about leave being cancelled and felt that, when leave had been cancelled, it was not always re-booked. Patients felt that staffing levels and availability, along with limited resources in respect of unit vehicles, contributed to their leave being cancelled or delayed. Following the on-site assessment, the trust provided data on cancelled leave for the 12 months prior to the assessment. The trust had 22 incidents recorded of leave being cancelled for this period across 4 of the 14 wards, meaning 10 wards had no recorded cancelled leave.

There was adequate medical cover day and night and a doctor could attend the wards quickly in an emergency.

Staff had received and were up to date with appropriate mandatory training. The training was appropriate for the patient group using the service. The overall average compliance rate for mandatory training across the 14 wards was 91%. Ward managers were aware of which mandatory training courses were lower for their ward and were working towards improving these figures.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

During the tours of the wards, we identified multiple chairs in general ward areas and seclusion rooms which had worn or ripped arm rests and cushions. This was a concern as it meant that staff would not be able to clean the chairs effectively. This was an infection prevention and control risk. This issue was escalated to both ward and senior management during the assessment.

Ward areas were generally clean and tidy.

Staff received mandatory training in infection prevention and control level 2, with an average compliance rate of 81% across the wards at the time of the assessment. Staff adhered to infection control principles, including handwashing.

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.

Patients’ medicines were reconciled on admission to the service (89% in 24h, November 2025). Medicines administration records were clearly completed and where needed the appropriate Mental Health Act authorities for prescribing were in place. However, we saw 2 examples, where these needed to be updated following a recent medicines change. We brought this to the attention of staff so that it could be promptly addressed. The trust had a stepped programme to support people who wished to, to self-administer medicines where safe and appropriate. Arrangements were in place for the supply of leave medicines and on discharge checklists helped to ensure smooth transfer of information, for example about Clozapine, to the new prescribing team.

A review of patients’ medicines and consideration of any individual physical health needs was completed as part of patients’ ward rounds with the consultant and wider team. A dedicated pharmacy team provided support for medicines optimisation. They had recently displayed posters on the wards to raise patients’ awareness of the pharmacy team and to encourage conversations about medicines. Patients prescribed medicines which require extra monitoring for example, lithium or clozapine, received individual conversations about the safe use of these medicines. A recent re-audit of the use of ‘when required’ medicines for agitation, insomnia, and anxiety against current guidelines showed significant overall improvement against trust baseline. A clear action plan was in place to help drive continued improvement.

Patients` physical health was checked following the use of rapid tranquilisation. Should any gaps in monitoring arise this was identified through trust processes, helping to ensure continuous improvement in this area. The trust had implemented a new booklet as part of an improvement programme to improve physical heath monitoring for patients taking clozapine. We saw some gaps in recording physical observations for one patient who had recently started clozapine. However, staff had promptly recognised and acted to improve this, so further records were clearly completed.

Care plans were in place to support patients with long-term physical health conditions as well as about medicines for their mental health. However, on occasion where rapid tranquilisation had been used, individualised plans lacked detail about the use of medicines as part of a strategy for managing the risk of violence and aggression. Similarly, some care plans for physical health conditions such as epilepsy or diabetes were more personalised than others. One staff team shared that they would like more training on the use of oxygen in respiratory illnesses.

The trust had a programme of medicines management and clinical audit with learning cascaded through network governance to the ward teams. Medicines incidents were reviewed, and action was taken to drive improvement where trends were recognised. For example, following reported incidents the pharmacy team delivered staff training focused on accessing medicines out-of-hours, with plans to re-audit staff awareness and confidence in this area.

We saw that medicines including controlled drugs were safely handled and should any shortfalls be identified these were appropriately addressed. Compliance with the trust’s required medicines training, including medicines administration, controlled drugs, clozapine and rapid tranquilisation was above trust target (80%).