Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well Led

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

Requires improvement: This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

At this assessment, the service was in breach of legal regulation in relation to Regulation 17 Good Governance.

This service scored 61 (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 and understood the provider’s vision and values and how they were applied in the work of their team. The Trust’s vision was “To work together, with compassion and care, to keep you well over the whole of your life.”Their values were “We are caring and compassionate, We are respectful and We are honest and transparent”
• The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service, including via the intranet. The vision and values were on the public website too.
• Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. Managers told us they explored strategic goals in appraisals with staff. Staff told us they had opportunities to attend role specific forums, for example for nurse consultants where change and transformation were also discussed.
• Staff could explain how they were working to deliver high quality care within the budgets available. Caseloads and staffing levels were variable across the teams, with the early intervention teams being able to respond quicker to referrals and have the opportunity to support patients to engage with community activities. However the community treatment teams were more challenged with staff vacancies and absence and high demand and waiting lists for the service. Teams had been creative with trying to address this with the use of agency staff and providing assessments at weekends.

• Leaders had the skills, knowledge and experience to perform their roles. Leaders that we spoke with had clinical roles in the past and brought that clinical experience to the role.
• Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. Leaders were aware of the pressures that their staff team were working under, especially in the community treatment teams. Examples of trying to support the team and improve the service included Sunderland West community treatment team who had refocused their weekly meetings to offer more targeted support and guidance. There were 4 meetings a month, one focused on business agenda items, another on complex case discussions to provide peer support and knowledge in trying to support patients to progress who may be stuck, another was positive and safe and the fourth focussed on wellbeing of staff. This meant opportunities were provided to support colleagues.
• Leaders were visible in the service and approachable for patients and staff. We saw managers who were allocated caseloads of patients due to staffing challenges, they delivered interventions and reviews to patients in the interim until they could be allocated to staff. We observed managers being present in the team offices and staff were approaching them for advice and guidance.
• Leadership development opportunities were available, including opportunities for staff. Staff told us how they had been supported by the Trust to develop professionally, including training to be non medical prescribers.

• Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. There were surveys for both patients and carers. Results from these were collated and could be filtered to team level for their review and action. A carers promise information leaflet explained to carers what to expect when their loved one was accessing services from the Trust, including how to give feedback, where to get support from and how to be involved in the Trust. Monthly Hope group online meetings took place for patients accessing the early intervention teams and their families to listen to other people who have experienced psychosis and share experiences and listen to others with the focus on hope and recovery. Carers spoke positively about the carer support group in North Cumbria that they attended.
• Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. Patient and carer involvement were standard agenda items at the quality and performance meetings.
• Patients and carers were involved in decision-making about changes to the service. Opportunities were available for patients and carers to be involved in the Service User and Carer Reference Group (A patient and carer led forum working in partnership with staff to support improvement of Trust services.), The Involvement Bank (opportunities for patients and carers with recent lived experience to be involved in a range of service development opportunities including recruitment and training of staff.) and be part of the Trust Membership (Members receive regular information about the Trust with opportunities to give views and elect people to the Council of Governors.)
• Patients and staff could meet with members of the provider’s senior leadership team and governors to give feedback. Triangle of care meetings took place in each locality to monitor and support the implementation of the six key standards as outlined in the Triangle of Care. These meetings were attending by patients, carers and staff.
• Peer supporters and carer leads had been recruited to most teams and had been very well received, with positive feedback from patients and carers.

• There were equality and diversity networks within the service. These were Cultural Diversity Staff Network, Disabled Staff Network and LGBT+ Staff Network. Staff also had the opportunity to access staff support groups in Mind, Health and Wellbeing Community and Armed Forces and Veterans Staff Association.
• Staff were able to apply to work flexibly e.g. flexible working agreements to account for personal circumstances such as caring responsibilities and health issues. We saw several staff with part time contracts and those who had taken leave for child caring responsibilities.
• The provider undertakes equality monitoring of staff within the service to ensure it is diverse in its make-up and representative of the patient group.

• There was not a clear framework of what must be discussed at a team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. We reviewed the team meeting minutes for 8 of the teams we visited and found the agenda, content and frequency was variable. For example, team meeting minutes included complaints at North Cumbria Community Treatment Team and North Tyneside Community Treatment Team. All other teams did not have complaints in their minutes. We were not sent minutes for team meetings in Gateshead and Newcastle. This meant not all staff were informed of the nature of complaints in their local area and any changes in practice. Learning from incidents was shared in 6of the teams we visited and had been sent the minutes for, however this was not discussed in the North Tyneside EIP andNorthumberland EIPminutes we reviewed. This meant not all staff were receiving the learning from incidents in meetings and an opportunity to improve practice.
• Staff had not implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level. A presentation had been created and shared with Associate Directors and Associate Nurse Directors in January 2025. 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.
• Staff undertook or participated in clinical audits. The audits were not sufficient to provide assurance and staff had not acted on the results when needed. A re-audit of Care Planning and Personalisation of Care Planning had been undertaken. The audit was previously signed off at the Clinical Effectiveness Committee on 12 May 2023 with areas of concern and moderate risk. At the recent re audit, signed off on 10 January 2025, although progress had been made, the conclusion was that the service continued to have minor areas of concern with moderate risk. The national clinical audit of psychosis re audit showed a deterioration, the results demonstrated that there were two areas in which the Trust required improvements where previously the rating had been performing well. These were Supported employment and education programmes and outcome measures. This resulted in the Trusts’ overall result changing from performing well, to needing improvement.
• Staff did not always understand the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients. The significant incident in the community that senior leaders asked the learning to be shared with teams included learning regarding communication between crisis teams and community treatment teams to be responsive to deteriorating mental health of patients.
• Management of risk, issues and performance were monitored via the Performance and quality dashboard which managers had access to and these were reviewed and discussed with senior leaders.
• Staff had access to the risk register and added items to the register. Items on the risk register for the service included the environments, lack of space for appointments with patients, staffing challenges, waiting lists, floating caseloads due to staffing challenges, lack of staff to fulfil the physical health clinics.
• The environmental assessments varied across the teams, 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. This meant there was no consistent oversight of the safety of the buildings and how staff should mitigate the risks.
• Staff were not always working in safe accessible conditions, buildings where assessments and patient sessions took place, did not all have alarms (Grassbanks, West Farm House, Molineux St and Portland Square did). Managers told us that staff could use the lone worker device however it would not be as quick to summon assistance as if there were alarms in the rooms. As the lone worker device alerted an external team before contacting the manager of the team. The security risk assessment for Benton View 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.” Their conclusion and recommendations included to install alarms. Houghton Day Unit did not have lockable doors between clinical and non clinical areas. This impacted on the management of any potential risk of harm to others and could result in possibleinformation governance breeches. This had been added to the risk register. Several buildings were not accessible, with several stairs and no lifts, this meant disabled staff who could not manage stairs would not have been able to work there and staff had to arrange to meet patients either in their own homes or other venues including clinics.
• Staff did not always have access to the equipment and information technology needed to do their work. Due to the number of teams based at Greenacres, staff were asked to hot desk, with limited space to work and access facilities, this had been added to the risk register. The information technology infrastructure, including the telephone system, did not always work well and did not always help to improve the quality of care. Due to changes in the computer system, there had been an error which looked like patients had been discharged, administrators were not aware of this and had told a patient they had been discharged when they hadn’t which had had a detrimental impact on their recovery and engagement in services.
• Information governance systems included confidentiality of patient records.
• Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care. Managers used the dashboards to review performance.
• Leaders had not ensured that policies and procedures were fully implemented, in relation to lone working, 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.
• Leaders did not ensure there were complete and contemporaneous care records for patients, we reviewed 68 care records. Of these, 3 records did not have a care plan in place (4%), 11 care plans were not up to date (16%), 16 care plans were not personalised, holistic and recovery orientated (24%), 3 records did not have a risk assessment in place (4%) and 6 risk assessments were not up to date (9%).
• There were inconsistent approaches to the management of waiting lists across the community treatment teams. It was difficult to get an accurate view of how many people were waiting for an assessment as the dashboards were quite often different to the locally held spreadsheets. There was no formal process to assess risk whilst people were waiting for an assessment. However once patients were assessed, there were good systems in place to review patients, if people were waiting for treatment where they were allocated a named worker who rang them monthly and had 3 monthly face to face contact/review. However we sampled examples of contact and found there were some gaps. This meant risk was not being managed whilst people were waiting for a service.

• Directorate leaders engaged with external stakeholders – such as commissioners. We sought feedback from stakeholders and received feedback from 5 stakeholders. Stakeholders told us that links with primary care colleagues was improving, with a greater understanding of both services, opportunities were available to discuss patients to ensure the most appropriate interventions and pathways were considered in parts of the Trust, it was hoped this would be introduced across the service as feedback in some areas was that there was a lack of clarity about pathways and limited communication with the community teams supporting patients. Stakeholders told us staff within the community teams were skilled and knowledgeable, however as the teams were stretched it was difficult to provide timely interventions. Access to community treatment teams was a concern raised by stakeholders, with the length of time patients were waiting for intervention. This had a negative impact on patients being able to access support from other services due to referrals needing to be made by the community treatment teams. Concerns were shared by stakeholders regarding discharge of patients from community treatment teams, including lack of oversight for patients with 117 aftercare arrangements and patients who weren’t engaging with the team but required more of an assertive approach. Stakeholders shared that communication with the teams could be a challenge, with changes made to the availability of duty workers and lack of details of who to contact to discuss complex patients. This meant the service were not always collaborating and working in partnership with other services for the benefit of patients.
• Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback. Triangle of care meetings took place in each locality to monitor and support the implementation of the six key standards as outlined in the Triangle of Care. These meetings were attending by patients, carers and staff. Staff told us that senior leaders were approachable and we saw they were visible during the assessment within teams and staff were engaging positively with them.

• Staff were not always given the time and support to consider opportunities for improvements and innovation and this led to changes. Staff were very stretched within the teams, with vacancies and absences of staff and high demand for the service. This meant that staff focused on the interventions with patients and found it difficult to accommodate other meetings and opportunities for sharing ideas, we saw staff having to postpone supervisions due to workload.
• 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. This meant leaders had not ensured that the service met the requirements of the changes in legislation and did not ensure that staff had all of the necessary training to meet the needs of the patients they were caring for.
• Staff had opportunities to participate in research. A sleep study was taking place in the early intervention in psychosis teams. Staff told us of the community depot processes – creating clinical excellence improvement workshop that had taken place where staff were involved in the creation of a best practice approach that could be consistently deliverable across the Trust.
• Innovations were taking place in the service. Sunderland and South Tyneside Early intervention in Psychosis had completed a pilot project to offer a peer support welcome meeting to new service users and their families and carers who were accepted as experiencing a first episode of psychosis. This was well received and a report of this was published in the Leading Minds publication.
• Staff participated in national audits relevant to the service and learned from them. The national clinical audit of psychosis re audit showed a deterioration, the results demonstrated that there were two areas in which the Trust required improvements where previously the rating had been performing well. This meant there had been a deterioration since the last audit had taken place.