Cumbria, Northumberland, Tyne and Wear 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

Safe:

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 changed to requires improvement.

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.

At this assessment, the service was in breach of legal regulation in relation to Regulation 18 Staffing.

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.

• The service had 2 severe harm incidents in the last 12 months from March 2024 to February 2025. Learning from the incidents included improved communication with neighbouring Trusts where patients were placed out of area.
• All staff knew what incidents to report and how to report them. Including incident reporting and escalating to a senior colleague. The service completed early learning reviews, after action reviews and improvement plans to identify learning following incidents.
• Staff reported incidents that they should report. Records showed incidents had been reported and were then shared with senior colleagues for their review and action.
• 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. There had been 2 incidents meeting the duty of candour threshold in the months between July 2024 and February 2025.
• Staff mostly received feedback from investigation of incidents, both internal and external to the service. There had been a community learning webinar in October 2024, where information regarding incidents that occurred in external providers in community settings was shared with senior colleagues and a discussion about the learning and how the service could act on that took place.
• A presentation had been created and shared with senior leaders to communicate learning from an incident in the community. Senior leaders had been asked to meet with staff teams to discuss this and identify changes in practice. Minutes of meetings showed that learning from this incident had not been shared with teams, however learning from other incidents was shared from incidents in 6 of the teams we visited and had been sent the minutes for, however this was not discussed in the North Tyneside EIP and Northumberland EIP minutes we reviewed. This meant not all staff were receiving the learning from incidents in meetings and an opportunity to improve practice.
• There was evidence that changes had been made as a result of feedback. Information provided by the service showed changes in practice following incidents including using the multidisciplinary team to hold complex case discussions.
• Staff told us they were debriefed and received support after a serious incident.

• 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 within the early intervention in psychosis teams. There was consistent referral processes and criteria across the early intervention teams. However the assessment processes in the early intervention teams varied with some teams conducting joint assessments and other teams assessing with one practitioner.
• The referral process for the community treatment team varied across the geographical areas, dependant on commissioning arrangements, with Sunderland having an initial response service who triaged all of the referrals then allocated them to the teams for assessment.Following the assessment there was a multidisciplinary meeting where the assessor presented the assessments, a decision was made in the meeting about whether the referral would be accepted and if so what interventions would be offered. Gateshead received the referrals directly to the team, with a worker allocated to review the referrals. Multidisciplinary meetings took place daily to decide if people being referred would be offered an assessment. In North Cumbria East Community Treatment Team there was an assessment pathway clinical lead and a treatment pathway clinical lead. They oversaw the management of the waiting lists for assessments and treatment.
• Staffing challenges, vacancies, sickness and difficulties recruiting to posts contributed to significant delays in people being assessed for the community treatment services. Information provided by the trust following the on site assessment showed that Newcastle North and East Community Treatment Team had 202 people waiting for an assessment, both Gateshead East Community Treatment Team and Sunderland West Community Treatment Team had 98 people waiting for an assessment, South Northumberland Adult Community Treatment Team had 88 people waiting for an assessment, North Cumbria Community Treatment Team had 158 people waiting for an assessment. North Cumbria had the highest number of people waiting for an assessment with 300 people waiting for an assessment when we were on site. They had introduced assessment initiatives with the use of bank staff, offering assessments at a weekend and this had reduced the wait time from 9 months to 7 months for a routine assessment. There was no process in place for the teams to assess the risk to patients waiting for an assessment, they were reliant on people making contact to the service if risk changed. This meant the service were not assessing the risk to people waiting for an assessment.
• Waiting times were on the Trust’s risk register. Waiting lists were reviewed at monthly waiting list meetings in Sunderland and South Tyneside, however minutes showed the meetings did not take place monthly. Waiting lists were also reviewed in the monthly access oversight group and monthly Community Care Group Operational Management Group Quality and Performance meeting.
• Once assessed people were waiting for treatment to begin. People were contacted by practitioners by phone and invited for face to face reviews before being allocated to a community practitioner. This meant risk was being reviewed once assessed and whilst waiting for interventions.
• Due to vacancies in the teams and staff absence, managers were holding caseloads of patients in Sunderland West Community Treatment team of 140 patients at the time of on site assessment and 172 at Gateshead East Community Treatment team. Patients received phone calls to monitor their circumstances and mental state however did not receive any interventions. This meant patients were not receiving the support they required.
• Patients had to wait if they were being transferred from another mental health team, although dependent on reason for referral, for examples if patients had a psychosis they would be prioritised for allocation.
• Records showed staff were involved in referring patients to other services and met with social care colleagues where needed.

• Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Staff completed training in safeguarding adults levels 1, 2 and 3 and safeguarding children levels 1, 2, and 3. Training compliance levels were above 80% for all teams we visited except North Cumbria East Community Treatment Team whose compliance was 100% for safeguarding adults level 1, 69% for safeguarding adults level 2 and 78% for safeguarding adults level 3 and 94% for safeguarding children level 1, 69% for safeguarding children level 2, and 81% for safeguarding children level 3.
• Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff told us and records showed examples of interpreters being used and referring patient for an autism assessment.
• Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Staff told us and records showed examples of joint work with children’s services in relation to child protection.

• We reviewed 68 care records during the assessment.
• Staff did not always involve patients in care planning and risk assessment. Of the records reviewed, 3 records did not have a care plan in place, 11 care plans were not up to date, 16 care plans were not personalised, holistic and recovery orientated, 3 records did not have a risk assessment in place and 6 risk assessments were not up to date.
• Staff communicated with patients so that they understood their care and treatment, in the appointments and home visits we observed, staff explained to patients the reason for the appointment and agreed next steps. However for patients with additional needs, records did not always include any reasonable adjustments that were needed to effectively engage and communicate with those individuals.
• Staff enabled patients to give feedback on the service they received via surveys.
• Staff ensured that patients could access advocacy. Details of how to contact advocacy and other services were displayed in the waiting rooms. The patient information leaflets also included contacts for the independent complaints advocacy.

• Staff completed assessments of the environment in relation to Asbestos management, electrical installation condition, fire risk assessment, gas safety and Legionella.
• We requested environmental and building risk assessments for all teams we visited. Information submitted was not consistent across the bases, some were survey reports, which noted the fabric of the building and the physical condition and any repairs required, North Tyneside Community Treatment team, Newcastle North and East Community Treatment Team, Early Intervention in Psychosis Team Gateshead and Early Intervention in Psychosis Team Northumberland had a ligature risk assessment in place, which included control measures.
• Early Intervention in Psychosis Team Newcastle and South Northumberland Adult Community Treatment Team’s ligature risk assessment was partially completed with several areas blank. This meant ligature risk assessments were completed to a different standard with inconsistent information available to staff. There had been a patient safety incident within the Trust’s estate involving a community patient and the Trust had not taken all the required actions to mitigate the risk on all sites, this meant learning following incidents was not always implemented.
• Other teams had security risk assessments in place. The security risk assessments include the risk to staff in the environment. There were security risk assessments completed for 3 of the 12 teams visited. Early Intervention in Psychosis Team North Tyneside’s security risk assessment was detailed and included pictures of the environment, the risk assessment stated “The consultation rooms doors do not have observation panels, and would limit staff alerting that an incident take place. Consultation rooms do not have a Staff Attack System in place.” Several recommendations were identified including installation of alarms and the completion of lone worker risk assessment for staff. The security risk assessment for North Cumbria East Community Treatment Team was detailed and included pictures of the environment. Several recommendations were identified including a review of the front door, an authorising access to the building and the completion of lone worker risk assessment for staff. The assessments showed risks to staff that were not mitigated.
• Although the majority of staff had discreet lone worker devices for use in the community, not all consultation rooms had alarms in them and staff told us if they used their lone worker device in there, it went to a central team before contacting the persons manager so there could be a delay in summoning assistance. Two teams said there was a delay on accessing devices in Gateshead East Community Treatment Team and early intervention in psychosis team Gateshead, this meant staff could not do home and community visits alone.
• The service were not following their Lone Worker Policy dated February 2023, the policy stated that staff should have a lone worker risk assessment and these were not in place. This meant there was no record of possible risks to staff when working alone and how to mitigate them.
• Clinic rooms were fully equipped with equipment relevant to the appointments that took place there, for example blood pressure machine and electrocardiogram machine. However resuscitation equipment and emergency drugs were not stored there. There were gaps in fridge temperature and clinic temperature records in Gateshead clinic for January and February 2025, gaps in fridge temperature records in North Cumbria East clinic for December 2024 and January 2025 and gaps in fridge temperature records in Newcastle North and East Community Treatment Team and Early Intervention in Psychosis Team – Newcastle for February 2025. This meant the service could not be assured that medicines were stored at a safe temperature on these dates.

• We reviewed staffing data provided by the trust and found the following teams had vacancies:

Northumberland Adult Community Treatment Team Additional clinical services 31% and Nurses 16%.

Early Intervention in Psychosis Team Northumberland Additional clinical services 5% and Nurses 4%.

North Tyneside Community Treatment Team Medical 7% and Nurses 4%.

Newcastle North and East Community Treatment Team Additional clinical services 8%.

Early Intervention in Psychosis Team - Sunderland and South Tyneside Nurses 29%.

Gateshead East Community Treatment Team Allied Health Professionals 50% andNurses 17%.

Early Intervention in Psychosis Team – Gateshead Medical 17% and Nurses 0.5%.

North Cumbria East Community Treatment Team Additional clinical services 19% and Allied Health Professionals 26%.

• Average turnover over the last 12 months across the teams we visited was an average of 11%, with the highest at Early Intervention in Psychosis Team Northumberland with 21% and the lowest, with none at Early Intervention in Psychosis Team - Sunderland and South Tyneside.
• Sickness over the last 12 months across the teams we visited was an average of 8%, with the highest at Early Intervention in Psychosis Team Northumberland with 12% and the lowest was North Tyneside Community Treatment Team with 4%.
• When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels.
• When agency and bank nursing staff were used, those staff received an induction. The Trust induction policy included a checklist for senior staff to work through with new staff at a local level.
• Not all staff had received and were up to date with appropriate mandatory training. We reviewed the information provided by the trust and found that the lowest compliance was North Cumbria East Community Treatment Team with 53% compliance, North Cumbria Early intervention in Psychosis team with 61% compliance, Newcastle Early intervention in Psychosis team with 60% compliance and South Northumberland community treatment team with 71% compliance.
• We reviewed the training identified as mandatory and found that Learning disability and Autism training was not mandatory, this meant the service were not meeting the requirement from the Health and Care Act 2022. Since 1 July 2022, all registered health and social care providers have been required to provide training for their staff in learning disability and autism, including how to interact appropriately with autistic people and people who have a learning disability. We reviewed training compliance levels for learning disability and autism training and found for learning disability training all teams we visited had compliance levels of less than 41%. For autism awareness training, only 2 teams; Gateshead early intervention in Psychosis team and North Cumbria early intervention in Psychosis teams had training over 70% compliance, with 71%. We found the teams were supporting autistic people and 3 care records did not show any reasonable adjustments staff were making for autistic patients, which showed a gap in staff’s knowledge. Following the on site assessment, the provider told us that learning disability and autism training is now mandatory.
• Staff told us they would benefit from training in drug and alcohol awareness due to the needs of the patient group using the service. Information provided by the Trust showed that staff had access to Co-occurring Mental Health Substance Misuse Training, 7 of the teams we visited had accessed the training, however this was not a mandatory course for staff. This meant there was training available, however not accessed by all teams.

• Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date. Tours of the clinic rooms showed they were well stocked, clean and tidy.
• Most teams we visited were clean, had good furnishings and were well-maintained. However in the North Tyneside Community Treatment Team there were chairs with ripped fabric and foam exposed, we highlighted this to staff at the time who told us they would address it. Newcastle North and East Community Treatment Team clinic had a stained floor and peeling paint. There had been damage to buildings due to leaks at Newcastle North and East Community Treatment Team and Early Intervention in Psychosis Team - Sunderland and South Tyneside, however this was in staff only areas.
• Staff adhered to infection control principles, including handwashing. Staff working in the clinics and administering were bare below the elbow and we observed safe hygienic processes being followed.

• Staff followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) and did it in line with national guidance. We observed medicines administration in 3 depot clinics and a clozapine clinic. Staff completed the required physical health checks on patients. We observed sharps and clinical waste was appropriately disposed of.
• Staff reviewed the effects of medication on patients’ physical health regularly and in line with NICE (National Institute for Health and Care Excellence) guidance, especially when the patient was prescribed a high dose of antipsychotic medication. We observed medicines being administered, staff asked patients about side effects they were experiencing and the impact on them. Staff also explored how to reduce the side effects with patients. Where concerning results were received, we saw staff responding quickly to do a home visit to conduct a physical health review.
• We reviewed depot prescribing and administration arrangements in teams where medicines were stored. We reviewed 49 prescription cards, we found prescription cards for depot medicines had been reviewed within 6 months. The allergy status was recorded in all cards except one.
• Records for prescribing and administration of medicines were paper based. There was one incident where a staff member had taken an administration card home with them following an administration in the community which meant records were not always within the clinics. The senior leader of the Trust told us there was plans to move to electronic prescribing which would remove this risk.