Cumbria, Northumberland, Tyne and Wear 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 good. At this assessment the rating has remained good.

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.

The Trust maximised the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

We reviewed 25 patient care records during the assessment. We found that staff completed a comprehensive mental health assessment of each patient in a timely manner at, or soon after, admission.

Staff assessed patients’ physical health needs in a timely manner after admission. A full physical examination, as well as a full set of bloods were part of the admission process by the medic. We saw evidence of ongoing monitoring, in particular blood pressure and pulse were checked daily (more if required) and weight was checked weekly (again, more often if required).

Staff developed care plans that met the needs identified during assessment. Care plans were personalised, holistic and recovery-oriented. Staff updated care plans when necessary.

The Trust planned and delivered people’s care and treatment with them, including what was important and mattered to them and in line with legislation and current evidence-based good practice and standards.

Staff 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.

Staff ensured that patients had good access to physical healthcare, including access to specialists when needed. The National Early Warning Score (NEWS2) system was used to identify when a patient’s physical observations indicated a medical referral. Patients requiring admission to an acute hospital were supported with this without undue delay.

Staff assessed and met patients’ needs for food and drink and for specialist nutrition and hydration. We saw that staff used the nationally recognised Malnutrition Universal Screening Tool (MUST) to assess patients nutritional needs. We saw evidence of seeking advice from other professionals such as dieticians, tissue viability nurses and speech and language therapist to prevent malnutrition and associated skin breakdown. The patients menu was adapted if needed to included high calorie food and supplements as well as being adapted to meet dietary requirements for those needing a special diet such as soft or pureed foods or those who were diabetic. We saw in patient care plans and on boards usually in the kitchen where meals were served from to alert staff to any special dietary requirements.

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, the teams comprised of occupational therapists, clinical psychologists, pharmacists, speech and language therapists, dieticians and carer support workers.

Staff were experienced and qualified and had the right skills and knowledge to meet the needs of the patient group. Although as mentioned above, staff training in dementia care was not mandatory for staff working on wards for people with a diagnosis of dementia. Whilst we saw good use of some specialist training such as dementia care mapping, the trust did not keep a record of which staff had completed this, so we were unable to say how many staff had received specialist training in dementia care.

Managers provided new staff with appropriate induction.

Managers provided staff with supervision and appraisal of their work performance. Across 7 of the 9 wards supervision was above 80% compliance, except for Oakwood and Ruskin wards where they were at 58% and 50% respectively. However, yearly appraisals were completed at above 80% compliance on only 4 out of the 9 wards. The following wards had below 80% compliance, Castleside 56%, Cleadon 63%, Roker 52%, Ruskin 55% and Oakwood 76%. Despite this when we spoke to staff they did tell us that they felt well supported by immediate managers and that their career development objectives were supported. They felt that managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge.

We requested the team meeting minutes for all the 9 wards we visited for the 3 months leading up to our inspection. We found from reviewing these that managers ensured that staff had access to regular team meetings.

Managers felt confident to deal with poor staff performance promptly and effectively. Disciplinaries within the service were very low with just one in the last 12 months. Likewise, there was one grievance raised by a member of staff in the last 12 months and this was resolved locally.

The Trust worked effectively across teams and services to support people, making sure they only needed to tell their story once by sharing their assessment of needs when they moved between different services.

Staff held regular and effective multidisciplinary meetings. This included the patient and if appropriate their carer. We found that multidisciplinary meetings were effective in planning the treatment and care of the patients, patients and their carers felt included in the process and were clear on the purpose of the meeting.

Staff shared information about patients at effective handover meetings within the team (for example, shift to shift). There were daily safety huddles whereby staff discussed the risks for patients, any incidents over the last 24-48 hours and any planned leave or appointments that day.

The teams had effective working relationships, including good handovers, with other relevant teams within the organisation, this included care coordinators.

The teams had effective working relationships with teams outside the organisation for example the local safeguarding team.

The Trust supported people to manage their health and wellbeing so they could maximise their independence, choice and control, 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.

Ward activities helped promote a healthy lifestyle for patients – for example walking groups, sports activities and cooking healthy meals.

The Trust routinely monitor people’s care and treatment to continuously improve it and to ensure that outcomes were positive and consistent, and that they meet both clinical expectations and the expectations of people themselves.

Staff used recognised rating scales to assess and record severity and outcomes.

Staff used technology to support patients effectively (for example, for prompt access to blood test results and online access to self-help tools).

The Trust told people about their rights around consent and respected these when delivering person-centred care and treatment. However, staff did not always request an opinion from a second opinion appointed doctor when necessary.

Referrals for a SOAD were not always completed in-line with recommendations stated in the MHA Code of Practice. During our recent mental health act reviewer visits to the Trust older adult wards in February and May 2025, we raised concerns that there were delays in referring for a SOAD. The Code of practice (CoP) specifically states that systems should be in place to ensure that a SOAD referral is triggered approximately 4 weeks before the 3-month treatment rule was due to expire. We found that on some occasions the SOAD referral was only done on the day the 3-month rule expired (albeit a section 62 form was in place to authorise urgent treatment). Despite this being raised, we reviewed the dates of SOAD referrals being completed during the time of our assessment and found that out of 24 referrals completed from May 2025 to June 2025, none were sent 4 weeks before the 3-month treatment rule was due to expire, 15 were sent less than 5 days before the 3 month rule was due to expire, with 4 of these being sent on the day the 3 month rule expired. Our concern was that these referrals were not being completed in-line with the recommendations of the CoP and in the case of Mowbray ward, was noted to have been an issue since at least 2021.

All wards were above 80% compliance with training in the Mental Health Act except:

• Woodhorn Ward 76%
• Ruskin Ward 65%
• Medical - OP Organic Functional South and Learning Disabilities None of the 4 staff had completed the training (However, consultants aligned to the inpatients wards had completed specific Responsible Clinicians training that sat outside of mandatory training)

Staff were mostly 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 implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were.

The provider 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.

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 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.

Care plans referred to identified Section 117 aftercare services to be provided for those who had been subject to section 3 or equivalent Part 3 powers authorising admission to hospital for treatment (if applicable). (R2.3)

Staff did regular audits to ensure that the Mental Health Act was being applied correctly and there was evidence of learning from those audits.

Mental Capacity Act training was combined with the Mental Health Act training so compliance for both was noted in one course. Therefore, compliance rates were the same as the ones noted above for Mental Health Act training.

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

There were 9 deprivation of liberty safeguards applications made in the last 12 months to protect people without capacity to make decisions about their own care.

These were highest in Woodhorn and Hauxley Wards.

The provider 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 provider 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 regarding 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.

Staff made deprivation of liberty safeguards applications when required and monitored the progress of applications to supervisory bodies.

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.