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 requires improvement. At this assessment the rating has changed to good.

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

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.

Description: We maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

Quality Statement Score: 3. We scored the service as 3. The evidence showed a good standard. 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 9 care records during our onsite 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. Patients received a full physical health assessment on admission, this included baseline observations for blood pressure, pulse, height and weight and electrocardiograms, as well as taking information around substance use, dietary intake and reducing tobacco dependency. We saw evidence of ongoing monitoring of physical health and patients were registered with a local GP to access care in the local community, in keeping with a rehabilitation focused way of working.

Staff developed care plans that met the needs identified during assessment. We looked at care plans for all 9 patient records that we reviewed. We found care plans to be person centred, holistic and recovery orientated. We saw that patients were involved in developing their care plans, particularly in relation to goal setting and future plans. Care plans were tailored to suit the individual interests of patients and were personalised. We saw evidence of patients who enjoyed swimming, cooking, cycling and music and how their care plans used those skills and interests to enable patients to access the local community and develop confidence and skills in these areas.

Staff updated care plans when necessary and we were able to see clear evidence of regular review and updates on the record system. Examples included a patient who enjoyed cycling who unfortunately suffered a fall from the bike whilst out on leave, the care plan and risk assessment had been updated to include action to take if this happened again and how best to support the patient.

Description: We plan and deliver people’s care and treatment with them, including what is important and matters to them and in line with legislation and current evidence-based good practice and standards.

3. We scored the service as 3. The evidence showed a good standard. 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 wellStaff 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. This included medication and psychological therapies, activities, training and work opportunities intended to help patients acquire living skills. The service provided a model of care based on a person‑centred, recovery‑focused psychosocial rehabilitation model, supporting individuals with complex mental health needs to develop independence, regain daily living skills, and enhance overall wellbeing.

Staff ensured that patients had good access to physical healthcare, including access to specialists when needed. All patients were registered with a local GP on admission to the service.

Staff assessed and met patients’ needs for food and drink and as the unit was completely self-catering, patients were engaged in food hygiene training, as well as educational sessions around nutrition and healthy eating. Patients were encouraged to take charge of their meal plans and food preparation, and staff supported in guidance on making healthier choices.

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. As well as doctors and nurses, there were support workers, domestic staff and administrators. Alongside this was a full therapy offer, this team included occupational therapists, occupational therapy assistants, clinical psychologists, pharmacists and a peer support worker.

Staff were experienced and qualified, and they had the right skills and knowledge to meet the needs of the patient group. Managers provided new staff with appropriate induction. Managers provided staff with supervision (meetings to discuss case management, to reflect on and learn from practice, and for personal support and professional development) and appraisal of their work performance.

Managers ensured that staff had access to regular team meetings. We reviewed the last 3 monthly team meeting minutes following our inspection. We found that these were well attended and followed a set agenda. Items on the actions log were kept on a tracker to enable staff to update on how progress was being made against actions. Safeguarding, incidents and the risk register were standing agenda items and were discussed in detail.

The percentage of staff that had had an appraisal in the last 12 months was 82%.

The average supervision compliance based on the available data over the past 6 months was 71%. The supervision figures were previously held on a different electronic system, this had presented some issues in accuracy and consistency of recording as the system was complicated. In December 2025, a new supervision recording system and dashboard was developed and launched in partnership with the digital team which simplified and improved accessibility for both supervisors and supervisees to record supervision in a timely manner. The new dashboard updated daily to provide real time oversight of clinical supervision compliance and further work was ongoing to establish a system for the storage of historical data. Therefore, some of the figures did not perhaps reflect the true compliance with supervision and appraisal. However, staff we spoke to all told us that they felt well supported in their role, that they received regular formal and informal supervision and felt that the appraisal process encouraged development in their role.

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. We requested a summary of all specialist training relating to rehabilitation in mental health care undertaken by staff in the last 12 months. This included the speciality doctor receiving a mental health rehabilitation endorsement, which was awarded following the successful completion of one year of mental health rehabilitation training. This endorsement was recognised by both the Royal College of Psychiatrists and the General Medical Council (GMC).

In addition to this, several members of the multidisciplinary team were undertaking further education and training to enhance their expertise and leadership capabilities, including; an MSc in Advancing Clinical Practice alongside Sensory Integration Training, a Level 7 Senior Leader Apprenticeship, incorporating an Executive MBA in Health and Care, Team Engagement and Development (TED).

In addition to this, the rehabilitation care group was collaborating with the Northwest Regional Network on the development of a Continuing Professional Development (CPD) accredited Mental Health Rehabilitation programme. The programme included specialist modules covering the history, foundations, and functions of rehabilitation care within mental health services, alongside dedicated modules exploring recovery approaches and their practical application. It also contained a module focused on supporting individuals with complex needs, including person-centred assessment, care planning, and decision-making. The trusts mental health rehabilitation services had participated in the pilot phase of the programme, providing feedback to support its ongoing refinement and development.

Managers dealt with poor staff performance promptly and effectively. Managers were clear that they felt confident to deal with poor performance and were supported by the human recourses team if and when required.

Mental Health Act

95% of staff had received training in the Mental Health Act. 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 the implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were.

The trust had relevant policies and procedures that reflected the most recent guidance.

Staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice.

Patients had easy access to information about independent mental health advocacy. The advocacy service regularly visited the ward and supported patients. We saw the advocacy area on the ward where patients could meet with the advocacy team when they were onsite, and also take information leaflets and read about advocacy support on wall displays on the ward.

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 ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this has been granted.

Staff requested an opinion from a second opinion appointed doctor when necessary.

Staff stored copies of patients' detention papers and associated records (for example, Section 17 leave forms) correctly and so that they were available to all staff that needed access to them.

The service displayed a notice to tell informal patients that they could leave the ward freely.

Staff did weekly audits to ensure that the Mental Health Act was being applied correctly and there was evidence of learning from those audits. These were completed by the Mental Health Act office and results shared with the staff at Wesham. The report used a red, amber, green (RAG) rating system to alert staff when reports or actions were nearing their compliance date to remind staff it was due.

Quality Statement Score: 3. We scored the service as 3. The evidence showed a good standard. 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 (MDT) meetings. We observed an MDT as part of our onsite inspection. We found appropriate members of the MDT attended apart from the psychologist who was not on site that day.

Staff shared information about patients at effective handover meetings within the team (for example, shift to shift).

The teams had effective working relationships, including good handovers, with other relevant teams within the organisation (for example, care co-ordinators, community mental health teams, and the crisis team). The community staff were invited to important meetings about patients and were involved in decisions regarding discharge and future care.

The teams had effective working relationships with teams outside the organisation (for example, local authority social services and GPs). Patients were registered with the local GP on admission to the service. Staff and patients reported a good relationship with them and easy access to appointments when required.

Description: We support people to manage their health and wellbeing so they can maximise their independence, choice and control, live healthier lives and where possible, reduce their future needs for care and support.

Quality Statement Score: 3. We scored the service as 3. The evidence showed a good standard. 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 – for example, through participation in smoking cessation schemes, healthy eating advice, managing cardiovascular risks, screening for cancer, and dealing with issues relating to substance misuse. Staff supported patients to maintain a healthy lifestyle by providing regular exercise groups to suit all patients’ abilities (swimming, walking, cycling). Patients were encouraged to make healthy choices in relation to diet, this included the fact that the ward was fully self-catering, meaning patients were supported to plan and cook their own meals. The patients were supported to make healthier choices, included preparing their own ‘fake aways’ rather than take aways and planning meals to include vegetables.

The ward had developed a quality improvement initiative to promote basic physical movement as part of a healthier lifestyle approach for patients. This focused on incorporating simple, accessible activities such as stretching, light exercise, and mobility routines into daily schedules to improve both physical and mental wellbeing. The aim of this was to try to increase patients engagement in physical activity, enhance mood, support recovery, and reduce the negative impact of inactivity often associated with mental health admissions. By embedding these movements into routine care and encouraging staff participation, the initiative supported a culture of holistic care, empowering patients to adopt sustainable, healthy habits that can continue beyond discharge.

Description: We routinely monitor people’s care and treatment to continuously improve it and to ensure that outcomes are positive and consistent, and that they meet both clinical expectations and the expectations of people themselves.

Quality Statement Score: 3. We scored the service as 3. The evidence showed a good standard. 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 such as Health of the Nation Outcome Scales. Dependent on the stage of rehabilitation patients were at, this could mean small improvements over a longer length of time. This meant improvement was sometimes difficult to formally measure, but care plans and goal setting were used to record what the patient wanted to achieve and to set realistic timescales for this. Occupational therapist used functional assessment tools to track improvements in patients ability to carry out activities of daily living. We also saw ratings scales used for things such as mood, medication side effects and symptoms of psychosis. The readmission rates were also used as a measure of patient outcomes, with low readmission rates meaning out of 13 patients discharged from the service, 9 were not readmitted within 12 months.

Description: We tell people about their rights around consent and respect these when we deliver person-centred care and treatment.

Quality Statement Score: 3. We scored the service as 3. The evidence showed a good standard. 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. 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. We were able to see from reviewing patient records that patients were supported with things such as planning future care, finances and options for medication and treatment.