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 inspection we rated this key question requires improvement. At this inspection the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. There were high levels of staff vacancies across the service and wards were often below the required number of staff to maintain safety. The number of staff, band four and above, compliant with training in safeguarding was below the trust target. Some ward environments had not been maintained as well as others. However, since our last inspection the trust had made improvements to ensure physical health recording took place after the administration of rapid tranquilisation, Venous Thromboembolism (VTE) risk assessment took place and Clozapine monitoring was completed.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff knew what incidents to report and how to report them. Incidents and concerns for safety were raised in daily morning huddles to ensure incidents were reported appropriately. Staff reported serious incidents clearly and in line with trust policy. The service reported 14 serious incidents between January 2024 to December 2024, seven of which had been fully investigated and signed off by senior managers with actions agreed. Seven other reviews were ongoing. All had an urgent review in line with trust policy. Incidents involved the death of five patients who were detained under the Mental Health Act. Following these incidents the trust has worked with external partners to improve discharge procedures and implemented new training regarding the searching of patients returning from leave. The service had no never events on any wards. Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation when things went wrong. Between January and December 2024 there had been 100 incidents where the duty of candour threshold was met. Managers de-briefed and supported staff after any serious incident. They investigated incidents thoroughly. Patients and their families were involved in these investigations. Patients told us they were given feedback when they complained and that they were aware how issues they had raised were resolved. Staff received feedback from investigation of incidents, both internal and external to the service as well as looking at improvements to patient care. Staff told us they discussed incidents not only in team meetings but also as soon as practicable after incidents. There was evidence that changes had been made because of feedback. Managers had implemented new training programmes to ensure staff conducted searches appropriately.

Managers monitored the number of patients whose discharge was delayed and took action to reduce the delays. In the previous 12 months there had been 449 delayed discharges which was over eight a week across all 21 wards. Of these, 67.7% (304) were related to waiting for accommodation or social care provision, which were provided by organisations outside the trust, to be made available. The staff worked closely with community teams and care co-ordinators to plan discharge, and all patients had a discharge plan.

We saw meetings which discussed discharges and set dates for patients to be discharged. However, there had been an unsafe discharge prior to our inspection which had resulted in a major incident and at The Harbour we saw a discharge meeting arranged giving the community team only an hours’ notice to attend.

Each area had its own protocols for discharge procedures. New protocols had been implemented at Chorley to improve discharge procedures.

Staff knew how to recognise adults and children at risk of or suffering harm and worked with other agencies to protect them. Staff discussed any incidents that had occurred in the previous 24-hours at safety huddles to ensure all safeguarding concerns were captured and reported. Between January and December 2024 staff had made 238 adult safeguarding referrals and two child alerts. Not all staff had completed safeguarding mandatory training. Staff in bands four and above were required to complete safeguarding training at level three, however only 70.28% of staff were up to date with this. Staff in bands below band four completed safeguarding level two training and 86.18% of staff were up to date with this.

We reviewed 112 care records. Staff completed risk assessments for each patient on admission, using a recognised tool, and reviewed this regularly, including after any incident.

Staff made every attempt to avoid using restraint by using de-escalation techniques and restrained patients only when these failed and when necessary to keep the patient or others safe. This service had 2331 incidences of restraint in 2024.

Byron ward had the highest incidents of restraint (221).

Across the service there had been 831 rapid tranquilisation incidents with one patient being involved in 151 of those incidents. We were unable to review this patient’s records as they were no longer a patient within the service at the time of the inspection. There were 466 incidents of seclusion with both Byron and Calder having 51 each.

There were no long-term seclusions.

Staff participated in the provider’s restrictive interventions reduction programme, which met best practice standards. We saw patients on 1:1 observation, most patients were on general observations with those considered to present a current risk on 15-minute observations. Patients were risk assessed, and we saw risk assessments changed to reflect incidents as they occurred.

Staff in most locations completed and regularly updated thorough risk assessments of all ward areas and removed or reduced any risks they identified. During the inspection we reviewed both environmental and ligature risk assessments. These were generally well written. Staff on most of the wards we visited knew about any potential ligature anchor points and mitigated the risks to keep patients safe. For example, all staff conducting observations were able to tell us what and why they were conducting observations. Staff had completed fire risk assessments for all buildings, and there was fire evacuation plans specific to each ward. All patients that needed them had personal emergency evacuation plans (PEEP) in place. Most ward areas were clean, well maintained, well-furnished and fit for purpose. There was a mixture of accommodation from newly designed and modern buildings to older adapted accommodation. All wards were well furnished with furniture that was well maintained and fit for purpose. However, we did find on Churchill ward damage had been caused to noticeboards, there was a window boarded up and a patient had damaged the nurse’s station recently. On Buckley ward we found graffiti, the window into the seclusion room was badly scratched, and in bedroom 8 the walls in the en-suite were badly scratched and the tv cabinet was missing off the wall. The trust told us all damage was due to one complex long term patient, and had been reported and awaiting repair work. At Barrow we found the main and female lounge TVs had not been replaced (they were as soon as we identified this to staff). At Orchard ward we found two large plant pots that were full of cigarette butts and other litter.

Establishment levels were set by the trust. Managers calculated and reviewed the number and grade of nurses, nursing assistants and healthcare assistants for each shift when planning rotas. The ward manager could adjust staffing levels according to the needs of the patients. Each location held daily safety huddles to assess staffing on each unit and consider any shortfalls. The service had high vacancy rates. The service had 810.40 whole time equivalent posts and of these 124.81 were vacancies. This was a vacancy rate of 15.4%. Nursing vacancies were high, there was a working time equivalent of 283.46 posts (including ward managers) with 44.83 vacant, meaning the vacancy rate for nurses was 15.8%. There were also 34 nursing associates to support care. Hyndburn ward at Blackburn had 4.63 nursing vacancies, while three wards at The Harbour (Shakespeare, Churchill and Orwell) had combined vacancies of 13.03, while also at The Harbour Stevenson ward had 2 nursing staff above their establishment.

On the day we visited Churchill we found it to be below the recommended level of staffing by two staff. However, it was noted that severe weather conditions had impacted on staffing levels on this day and the Trust had initiated business continuity arrangements. We examined 28 days of shifts from 9th December 2024 to 5th January 2025 for all 21 wards, which included earlies, lates, and nights (we excluded the twilight shift as this was not relevant to all wards). We reviewed a total of 1764 shifts. A comparison of the required number of staff based on ward establishments against the actual numbers of staff on shift, showed that 1461 shifts (82%) were run with either the number of staff required according to establishments or greater. However, these numbers did not take into account acuity of the ward including increased staff to manage patient observations and patient safety for example. By comparing the required number of staff overall as determined by ward staff, as opposed to the basic establishment numbers, against the actual overall number of on shift we found that only 313 shifts were run with the required number of staff, meaning 1451 shifts, or approximately 82% of shifts, did not run with the correct number of staff. The Trust told us they moved staff around to support with numbers, but staff told us that shifts regularly ran below minimum staffing levels. The trust were aware of, and were working to address, concerns in relation to staffing.

Staff followed infection control policy, including handwashing. They told us that they washed their hands to prevent infection, and that personal protective equipment was available. Managers had put in place audits to ensure staff cleaned all areas when required to do so and bedding and other soft furnishings were replaced according to the providers policy. Staff made sure cleaning records were up-to-date, and the premises were clean. We reviewed cleaning rotas and spoke with housekeeping staff; they were able to show us up to date and comprehensive records. During the inspection we saw continuous cleaning activity, and the ward was clean and tidy.

Medicines administration records were clearly completed and where needed the appropriate Mental Health Act authorities for prescribing were in place. Nicotine replacement therapy was available for people who wished to stop smoking. Since our previous inspection the trust had taken action and implemented new working practices to improve rates of venous thromboembolism assessment (71% complete in January 2024 to 87% in December 2024). Additionally, the trust had taken action to reduce risks around dispensing medicines with minimal time intervals between doses, such as paracetamol, and whilst there were occasional examples where there were still issues, this was largely improved. However, at the Chorley site (Worden ward)there was no dedicated space for pharmacy staff to dispense medicines, increasing the risk of errors. Where people were prescribed medicines requiring additional monitoring, this was usually completed. People’s physical health was checked following the use of rapid tranquilisation. However, on occasion care plans lacked detail about the use of medicines to support people experiencing anxiety or agitation following rapid tranquilisation, or where more than one medicine was prescribed. A trust audit (November 2023) similarly found that non-pharmacological (non-medicines) interventions were not always clearly recorded before offering ‘when required’ medicines. The trust planned to reaudit this (Quarter 4 2024-25). A rapid tranquilisation e-learning had been mandated, and compliance was moving towards the trust’s 80% target. The trust also audited rapid tranquilisation booklets to ensure physical health checks were completed. There was an improvement plan to improve physical heath monitoring for patients taking clozapine. A clozapine e-learning module had been mandated with average compliance above the trust’s 80% target (December 2024). We saw some clear comprehensive records, but also some records where occasional gaps in physical health monitoring remained.