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 requires improvement. This was because we found that blanket restrictions, for example some doors being locked, was a rule for all patients, rather than being individually risk assessed. This meant that some patients may have had restricted access to these rooms, without a valid reason.

All wards were safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff did not always assess and manage risks to patients when introducing or continuing blanket restrictions, there were blanket restrictions that were overly restrictive for a rehabilitation environment, such as locked activity rooms and laundry rooms, that were not individually risk assessed. However, 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 62 (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 have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

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. We scored the service

There had been no incidents reported at Wesham Rehabilitation Centre with a harm level of severe harm or death in the last 12 months. There had been no Patient Safety Incident Investigations (PSIIs) relating to the service during this period.

Staff knew what incidents to report and how to report them using the electronic incident reporting system at the trust. From our review of care records, we saw that staff reported incidents that they should report.

Staff we spoke with understood the duty of candour. They were open, transparent, and gave patients and families a full explanation if and when things went wrong. There had been no duty of candour reports at Wesham Rehabilitation Centre during the 6 months preceding our onsite inspection as no incident has met that threshold.

Learning from incidents was important to the service and incidents were reviewed by the whole team on a monthly basis. This encouraged an open approach to when things went wrong and shared learning was identified soon after the incident to ensure changes to practice were made as soon as possible to improve care. Incidents, including falls and medication-related events, were reported through the trust’s incident reporting system and reviewed through local governance and multidisciplinary forums monthly. This constant ongoing review of incidents had identified areas for improvement such as the consistency of risk assessments, quality of documentation, and effectiveness of communication during handovers. In response, the service had implemented targeted actions, including reinforcing the use of structured communication tools, standardising risk assessment documentation and clinical documentation and introducing visual safety prompts to highlight high-risk patients. This had led to an improvement in incidents of this type being reported over the months following the intervention. Any incidents relating to fires were shared with the treating tobacco dependency team, who used this information to provide either patient specific assessments and interventions or support to the ward team to manage this.

Learning from incidents was proactively shared with the team both from incidents within the rehabilitation ward and the wider trust. This was done through daily safety huddles, team meetings, clinical supervision, and targeted staff training. This ensured that staff at all levels were aware of emerging risks and required practice changes. The impact and effectiveness of all of the above, was monitored through regular audits and governance reporting to evidence a positive safety culture.

Description: We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different 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 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. We reviewed 9 patient records during our onsite inspection. We found that a thorough risk assessment was always completed. The risk assessments 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 service and post-discharge. We saw that appropriate professionals were invited to attend meetings about the patient’s care on the ward as well as being involved in their discharge plans.

Description: We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

1. We scored the service as 1. The evidence showed shortfalls. The service did not always review blanket restrictions on an individual basis. This meant that they did not always work well with people to understand what being safe meant to them and how to achieve that. However, they had a good relationship with external partners such as the local authority safeguarding team and reported a positive relationship. They did concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They shared concerns quickly and appropriately.Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Staff received training at the appropriate level for their role, and compliance levels were as follows; Level 1 100%, Level 2 93%, and Level 3 90%. We reviewed the last 5 safeguarding referrals made by the ward to the Local Authorityand found these had been reported correctly, quickly and feedback was provided on the outcomes. We saw evidence of various issues being reported, including financial abuse, self-neglect and fraud.

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.

Staff followed safe procedures for children visiting the service. There was a visiting room off the main ward area, this contained its own outdoor space as well as books and toys for children to use.

During the six month period 1 December 2025 to 31 May 2026, there were no incidents of restraint at Wesham Rehabilitation Centre. We reviewed the blanket restrictions and provided feedback at the end of our inspection that, due to the purpose of the service being to rehabilitate patients back into some kind of more independent living, certain rooms being locked such as the activity room, laundry rooms and quiet rooms, needed to be reviewed on an individual patient basis, rather than being locked for the whole patient group. Whilst we would not tell the service to remove these restrictions, we would want to see this reviewed according to individual patient risk, with a view to allowing access to those patients who were deemed lower risk.. We also noted that larger sharps in the patient kitchen were locked away, and counted in and out by staff, again whilst this may be necessary for some patients, the kitchen always had a member of staff designated to be in the kitchen and to oversee patients in this area. We gave feedback at the end of our inspection that again, we would want to see this individually risk assessed, rather than a restriction for the whole patient group, given that some patients were accessing long periods of leave in the community and potentially moving on to their own accommodation.

Mental Capacity Act

Over 90% of staff had had training in the Mental Capacity Act.

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

There were no deprivation of liberty safeguards applications made in the last 12 months to protect people without capacity to make decisions about their own care. Patients were either detained under the Mental Health Act or informal at the service.

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 trust 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.

Description: We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

Quality Statement Score: 3. We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks, . 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. 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 9 patient risk assessments and risk management plans during the assessment.

There were no episodes of restraint during the six month period 1 December 2025 to 31 May 2026.

Staff involved patients in care planning and risk assessment, all 9 patient records we reviewed showed evidence of patient involvement in care plans. We noted patients were involved in their goal setting and discharge plans, as well as participating in multidisciplinary team reviews. Patients had access to a copy of their care plan if they wished to have one.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties.

Staff enabled patients to give feedback on the service they received (for example, through surveys or community meetings). We reviewed patient feedback from patient surveys, community meeting minutes and reviewed examples of changes made from patient feedback . We found that patient survey results for the service were all positive. Comments from patients included, “Wesham is an amazing facility to help those who need it” and “I am always attended to very well, never need to ask twice”. We reviewed community meeting minutes and found these occurred weekly, with an average of 9 patients attending. We saw that feedback given during these meetings was used to make changes in the service. An example of this included patients requesting a computer to enable them to attend to their own administrative tasks, such as sorting housing and benefits. We also saw guest speakers attending the meetings, such as someone from a local service to try and support the patients into work.

Staff enabled patients to make advance decisions (to refuse treatment, sometimes called a living will) when appropriate.

Staff ensured that patients could access advocacy. The advocacy service had their own private area on the ward where they could meet with patients to discuss their needs. In this area, there were posters about patients right to an advocate and information about the type of things they could help patients with.

Description: We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

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. Although the ward layout did not allow staff to observe all parts of ward, blind spots were mitigated by staff presence and observations.

Staff had mitigated ligature risks adequately. There was a ligature risk assessment that was complete and up to date. This was completed annually and was last completed in June 2025. The ligature risk assessment was completed in 3 parts, part 1 was pre assessment, this was to try and understand the local risks on the ward and freely available items that could be classed as a ligature risk. Part 2, was the ligature point assessment, this took a tiered approach looking at the location of a ligature risk, a description of the ligature risk, existing controls and mitigation and made recommendations for actions. Part 3 was local information, this was information specific to the ward. Any items requiring action, were to be added to a tracker for the estates team to progress.

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

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

Description: We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

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.

Staffing levels were adequate, with minimal vacancies. The average sickness absence rate for the last 12 months was 7.3%. The number of shifts covered by bank staff was around a 70% to 30% split (with substantive staff covering 70% of shifts). However, the majority of staff working bank shifts were regular staff on the ward, so most staff working were familiar to the patients and knew the ward well.

Managers had calculated the number and grade of nurses and healthcare assistants required. At the time of our inspection, the staffing numbers for each shift were as follows; on a day shift there were 3 registered nurses and 4 healthcare assistants, and at night 2 registered nurses and 4 healthcare assistants. The number of nurses and healthcare assistants matched this number on all shifts for the week preceding our inspection.

The ward manager could adjust staffing levels daily to take account of patient need and acuity.

When necessary, managers deployed bank nursing staff to maintain safe staffing levels. When agency and bank nursing staff were used, those staff received an induction and were familiar with the ward.

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.

Staff had received and were up to date with appropriate mandatory training. Overall compliance was at 95%, with no training below 75%. The training was appropriate for the patient group using the service.

Description: We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

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.

Description: We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

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 (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) and did so in line with national guidance.

We reviewed all patient medicine records during our onsite inspection. We found these were clear and where necessary, the appropriate Mental Health Act authorities were in place. Patients told us that they had opportunities to speak with their staff team about their medicines, what options they had and were involved in decisions to change medicines.

The pharmacy team were heavily involved with the ward; they met with patients on a regular basis and held clinics and training sessions with patients around medication. There was a well established self-medication pathway and many of the patients were holding their own medications in safe boxes and self-dispensing, or attending the clinic room and putting their own medication out in their pot to take. There was a policy that guided the self-medication pathway.

Staff reviewed the effects of medication on patients’ physical health regularly and in line with National Institute for Health and Care Excellence (NICE) guidance, especially when the patient was prescribed a high dose of antipsychotic medication.