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

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. 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. The service was in breach of the legal regulations relating to Regulation 12 Safe care and treatment, Regulation 18 Staffing

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.

The trust had a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events were investigated and reported thoroughly, and lessons were learned to continually identify and embed good practices.

There were 25 serious incidents reported across all 9 of the older adult wards in the 12 months prior to our inspection. The most common themes were expected and unexpected deaths. Some of these incidents were in relation to falls. Staff told us that when they reported incidents, they received feedback in several ways, via team meetings, during supervision and email. We found that staff had a good understanding of the duty of candour and gave patients and their families an apology and an explanation when things did no go correctly. Debriefs were carried out and support was offered to staff following serious incidents and staff told us that they felt this was beneficial and felt supportive. Staff were able to tell us about changes made because of learning from incidents. An example of this was revisiting medicine competencies for qualified following a flurry of medication errors to ensure staff were refreshed and up to date.

The trust worked with people and their partners to establish and maintain safe systems of care, in which safety was managed, monitored and assured. The trust ensured 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 patient records whilst on site and found that a thorough risk assessment was completed detailing risks both to and from the patient were clearly gathered at the point of admission 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 the correct professionals were invited to attend meetings about the patients care on the ward and their discharge plans.

The trust worked with people to understand what being safe meant to them as well as with their partners on the best way to achieve this. They concentrated on improving people’s lives whilst protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and they mase sure they shared concerns quickly and appropriately.

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. Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate.

The staff we spoke with were able to give relevant examples of concerns they would report as safeguarding issues and could describe the process for reporting a safeguarding concern, including out of hours. 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 space off the ward in most areas where children could visit. Staff were aware of the Trust policy regarding children visiting inpatient wards and were able to explain how they would manage this safely.

Levels of restraint were relatively low for the patient group and low levels holds were used for the most part to assist with personal hygiene. Woodhorn ward was a particular outlier in terms of number of restraints. However, the Trust sent supporting information with this data to explain there had been two patients in particular who had accounted for over 40% of these restraints due to unusually high levels of distress.

The Trust had good oversight of restraint taking place on each ward. This includes a robust data set detailing all incident and restrictive interventions which can be accessed by teams, wards participate in quarterly discussions about restrictive practices and reduction of restrictive interventions agenda, and challenges around this, were brought to care group and Trust-wide attention at the Reducing Restrictive Interventions sub-group and steering group. The board were also briefed on this as part of their ongoing meetings regarding quality.

However, compliance with the Trusts managing violence and aggression training was low, with 5 out of 9 wards sitting at 71% or below compliance with the lowest being 65%. This meant that there was a risk that staff would not be able to respond to incidents safely using approved taught techniques, should an incident occur that required de-escalation or restraint.

There were low levels of blanket restrictions outside of what would normally be expected on an inpatient ward. For example, patients had access to their bedrooms during the day, outside areas were open for patients to access and visiting times were flexible (apart from protected mealtimes). There was a blanket restriction register in place, and this was reviewed on a regular basis to see whether those that were in place were still relevant and required to continue.

The trust worked with people to understand and manage risks by thinking holistically so that care met their needs in a way that was safe and supportive and enabled them to do the things that mattered to them.

We reviewed 25 care records across the 9 wards we visited. We found that staff completed risk assessments for each patient on admission, using a recognised tool, and reviewed this regularly, including after any incident.

Staff used de-escalation and distraction techniques well to reduce the need for physical restraint. Although this was sometimes necessary, mainly to provide personal care to patients who were confused and distressed, but also when patients became agitated and at time violent. However, we saw that restraint was always used as a last resort to keep the patient or others safe. This service had 965 incidents of restraint in 2024.

Rapid tranquilisation was not generally used very much. However, over the 6 months leading up to our inspection it had been used 76 times on Ruskin Ward. This was much higher than all the other wards and stood out as an outlier. Other wards generally used less than 1 per month with Cleadon Ward using 4, Oakwood 11 and Woodhorn 24. The increased use on Ruskin Ward was investigated by the inpatient care group and trust rapid tranquilisation Group, they reviewed the clinical need and treatment plan for the patient involved and the use of rapid tranquilisation administrations on Ruskin ward had subsequently reduced with effective treatment plan.

Observations varied across the 9 wards. Most wards implemented a traditional style of observations, whereby patients were checked on every hour, or intermittently throughout the hour if risk was higher, with 1-1 or 2-1 observations for more high risk patients. However, two wards had piloted and successfully implemented a new type of observations called zonal observations. This meant that staff based themselves at set points throughout the wards and remained there in turns throughout the shift. This had been embedded on Mowbray and Roker Wards, and we received very positive feedback about this observation style from both staff and carers. Due to levels of confusion in patients with dementia, they often wander and due to risk of both falls and agitation, this often meant that there was unwitnessed falls and patient on patient assaults in corridors on the wards. For the wards where zonal observations had been implemented, this had significantly reduced. This was due to the fact there was always staff members based along the corridors, who also had activity trolleys with them for patients to engage with. This made the zonal observation areas a hive of activity, with patients stopping to chat to staff, engaging in colouring and puzzles as well as reducing flashpoints for conflict as staff were there to intervene very quickly. As the zonal observation points had places for patients to sit and rest with staff, it was also having a positive impact on reducing falls.

Some wards were also implementing the sleep well initiative where suitably risk assessed patients were able to have reduced observations overnight to enable good sleep hygiene. This is a carefully managed process and not every patient is suitable for this level of observations. However, it is in line with national guidance by the world health organisation about reducing noise on inpatient wards during nighttime hours to below 35 decibels They also emphasise the importance of a conducive environment for sleep, including appropriate light levels, and advise against excessive noise, which can disrupt sleep and negatively impact patient recovery.

Staff involved patients in care planning where possible, and where appropriate always involved family and carers in the process, gaining important life story information for patients with a diagnosis of dementia. Likewise, when patients had limited capacity to understand information about their care, we saw staff ensuring that this was communicated to them in a way they could understand.

Staff enabled patients to give feedback on the service they received via surveys and community meetings.

Staff ensured that patients could access advocacy, and they were invited to meetings regarding decisions on patient care.

The Trust did not always detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care. Staff carried out annual risk assessments of the environment. To do this the trust used a document called a clinical environmental risk assessment orCERA to risk assess the environment on the wards. These would be carried out a minimum of 12 monthly. The CERA identified any residual significant risks relating to the environment. This document was not a ligature risk assessment as such as it did not list all ligature points on the ward nor did it score the level of risk, they would present to ascertain how they would be managed and by whom. It did, however, note some areas that were not anti-ligature. There was then a separate document called the risk register which did not note any risks around ligatures and a further document called risk register – open risk assessments, this document details ligatures in groups (for example, groups together all the garden ligatures, indoor ligature points and communal ligatures into one risk), This document does score the risk but again doesn’t really give staff any guidance on particular hot spots on the ward that were higher risk,there was no heat map of risks to show staff where the hot spots were, it also does not give staff any guidance on how to manage these risks other than via engagement. The information being spread across several different documents means there is a potential for staff to miss key information, high risk ligatures and how to safely manage the environment. When we asked staff on Hauxley ward to see the ligature risk assessment, staff told us they did not complete one. Over the previous twelve months (1 June 2024 to 31 May 2025) there have been eleven reported incidents in relation to ligatures. Ten were ligature with no anchor point and one was related to ligature making. We saw instances where the environment needed work carrying out to make the environment safe for patients. This was mainly on Oakwood ward. The outside garden area on Oakwood was a trip hazard. There was uneven surfacing and flagstones sticking up. There was a steep ramp down to the garden and the handrail to assist patients had been removed as it was deemed a ligature risk. However, this meant patients with sometimes quite severe mobility issues were navigating down a steep ramp to access the garden,potentially causing a falls risk. The doors to the garden were open and it was unsupervised. This meant there was a risk patients could have an unwitnessed fall due to the uneven flooring. Staff reported these issues have been raised since 2024. There were some environmental issues on Oakwood Ward, worn paint on doors and broken plaster. Again, staff explained this has been reported for two years but no decorating has yet taken place. This was an infection control risk as cleaning could not be carried out effectively with broken plaster and worn off paint on walls. Out of the 9 wards we visited, 7 were mixed sex. On Ruskin and Oakwood, males and females were not separated appropriately. On both wards, patient bedrooms were a mix of male and female as we walked up the corridors and although bedrooms were en suite, bathrooms with baths were not in a single sex area. There was no segregation of female areas by a door or signage. Although there were female only lounges, these contained just bare minimum furniture and did not feel like a welcoming space for patients. One relative told us their family member had been kissed by a patient of the opposite sex and that patients often walk in and out of each other’s bedrooms whilst they were visiting. The Trust was asked to provide the policy for same sex accommodation as well as any incidents of sexual safety or single sex breaches. The Trust told us there had been no breaches of single sex accommodation. However, the spreadsheet they sent us contained an incident of a male patient entering a female patients room, sitting on her bed and telling them they would kiss them. Staff had entered the room to complete general observations and found this incident ongoing. The Trust sent a Delivering Same Sex Accommodation Audit completed in June 2025 that stated all wards were compliant with same sex accommodation guidance. However, despite the audit asking the question if bedroom areas are segregated, the answer to this states yes, because the bedrooms are en suite and have privacy windows, it does not discuss the arrangement or bedrooms on the corridor and if these are intermixed. We asked the Trust to continue to review this risk and to carry out a risk assessment of this issue. Not all ward layouts allowed staff to observe all parts of the ward. Although in the main this was mitigated by use of observations, particularly on wards where zonal observations had been introduced. However, we did hear from relatives on Oakwood and Ruskin that patients had wandered into their relatives bedroom during visits, these wards did not use zonal observations and therefore there wasn’t always a member of staff located around corridors at all times. There was only one incident of this type logged on the Trusts incident system of a patient being in another patients bedroom in the 12 months leading up to our inspection. Most wards had easy access to alarms and staff were wearing them during our visit. On Mowbray ward, we were told by staff that they were short on alarms and some staff would have to go without an alarm to allow the inspection team to have one. Staff put this down to alarms going home with staff following a shift, usually temporary staff, and not returning them. Patients all had access to nurse call systems. Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. There were some differences in how the checks of the emergency grab bag were being carried out. The Trust policy states weekly or when items have been clinically used but it was being done weekly on Castleside and daily on Akenside. On Oakwood Ward we saw that the defibrillator bag was hung on a peg over the treatment couch in the treatment room. This could have been a risk if someone was lay on the bed and it fell, or if someone needed it during an emergency and staff were assessing someone on the bed. We fed this back on the day of our inspection to the manager on site

The Trust did not always 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.

Staffing establishment levels for each ward for day and night shifts had been calculated using the nationally recognised Mental Health Optimal Staffing Tool (MHOST) and were being reviewed every 6 months. Most wards were staffed up to or near to their establishment with Ruskin Ward being an outlier. At the time of our on site assessment there were 5 registered nurse vacancies on this ward. These had all been successfully recruited into, however, some of the recruited staff were still student nurses and 3 were not due to start until October 2025. This was similar on Oakwood ward where there were 2 vacancies for registered nurses that had been recruited into, but again these staff were not due to start until October 2025. There were also high vacancy rates for healthcare support workers across the two wards at Carlise, 17 in total. However, all these posts had been successfully recruited into and staff had imminent start dates. The low staffing establishment had been recognised by the Trust and escalated to an executive meeting held with the inpatient care group leads on 12 June 2025 to review the key risks areas and establish a task and finish group to oversee key hotspot areas. It was recognised that Cumbria was a difficult patch to recruit to given its isolated location and staff were aware of this and working to improve the staffing numbers.

The ward manager could adjust staffing levels daily to take account of case mix. When necessary, managers deployed agency and bank nursing and support staff to maintain safe staffing levels.Where there were shortfalls in staffing, the wards drafted in bank and agency workers to ensure staffing met the minimum requirements for safe care. Use of agency and bank staff was generally low for wards that were fully staffed and had no patients on increased observation levels. However, some wards with higher vacancies or patients requiring 2:1 staffing were using a higher percentage of bank and agency staff. When we spoke to staff on the wards we visited, we found that bank and agency staff had a good understanding of the patients they were caring for and understood their care and treatment needs.

There were nursing and support staff always present in the communal areas of the ward during our time on the wards. Patients and staff told us that escorted leave and ward-based activities were not usually cancelled due to staffing pressures.

Staff had not always received or kept up to date with appropriate mandatory training.Across the 9 wards we visited there were shortfalls in several training courses as follows;

• 8 out of 9 wards had 51% compliance or below, (with the lowest being 25%), for learning disability tier 1 training. In addition, 8 out of 9 wards had 70% compliance or below (with the lowest being 17%) for autism training. 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.The Trust had only made this training mandatory for older adult inpatient wards in April 2025, although it had been available to staff in the Trust since 2022. There was an action plan in place to ensure the older adult wards were at 80% compliance for this course by 30 September 2025.
• 5 out of 9 wards had 71% or below compliance (with the lowest being 65%) for prevention and management of violence and aggression (PMVA) training
• 4 out of 9 wards had 66% compliance or below, (with the lowest being 50%) for breakaway training
• Clinical supervision training was low on Castleside and Ruskin ward
• Medicines management training compliance was low on Rusin and Cleadon Wards

Although the mandatory training provided was generally what would be expected for the patient group. There was no mandatory dementia awareness training, this included wards that specialised in the care of dementia patients. The Trust sent us information about specialist training available to staff that was not mandatory, this included courses such as dementia and dementia Friends, dementia care mappers and dementia care mapping awareness. We saw good use of dementia care mapping on the wards we visited. However, the trust did not keep a log of who had completed specialist training, only mandatory and therefore we are unable to provide figures of how many staff have completed this training.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency on 7 out of the 9 wards. On Mowbray ward there was no permanent Consultant Psychiatrist and this had been the case for some time. Staff told us that this was making it difficult to get tasks completed for patients, such as renewing section 17 leave forms when they expired. There were several community consultants covering the ward, and this meant it was sometimes difficult for staff to get hold of the correct person in a timely manner. The Trust informed us in September 2025 that a consultant was now in post.

The Trust assessed and managed the risk of infection, detect and control the risk of it spreading and share any 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. One exception to this was Oakwood ward, where there were some isolated maintenance issues that remained unresolved such as worn paint on doors and broken plaster. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly.

Staff adhered to infection control principles, including handwashing.

The Trust made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, for example discussing the risk and benefits of medicines in dementia, including when changes happen. There was of learning from incidents and audits to support good practice.

Medicines were safely managed. Patients, relatives or advocates were involved in discussions about the risks and benefits of prescribed medicines for example, when antipsychotics were prescribed for people with dementia. Staff described how they provided medicines information in different ways and languages. They told us that when needed the speech and language team worked with pharmacy to provide individually tailored information to meet people needs. People who wished, and were able to self-administer medicines were supported to do so. Where required, the appropriate authorisation for the administration of mental health medicines was usually in place.

A wide review of medicines use was taken at weekly prescribing meetings to include for example, the use of ‘when required’ medicines and where applicable, covert (hidden) medicines administration. Appropriate safeguards were in place for the covert administration of medicines. However, a record of the best interests meeting could not be found for one person. The frequency of use of rapid tranquilisation (an emergency measure using injectable medication to quickly calm a severely agitated person) was kept under frequent review to help ensure its use was proportionate. However, on occasion although patients were monitored, there were gaps in the record of physical health monitoring following administration. The trust was implementing actions following a trust-wide benchmarking audit of rapid tranquilisation (reported October 2024) including a focus on continuous improvement on recording post dose monitoring.

People’s medicines needs were considered on discharge from hospital. Following a recent audit (March 2025) a new discharge form was designed to help ensure the quality of the information passed to people’s GPs. The trust also made electronic referrals to patients’ usual community pharmacy on discharge to help them access extra support with their medicines.

Pharmacy support was embedded into ward teams supporting oversight for medicines governance. The trust had identified a medicines incident theme regarding medicine safety during transfer of care. Actions had been identified to support improvement but had not yet fully embedded. We found one example where medicines changes on discharge from the acute hospital had not been promptly reviewed on readmission to the trust. Other trust learning actions included the roll out of patient photographs to support identification when administering medicines, and the implementation of an electronic solution to improve oversight of the use of medicines patches. The trust also participated in benchmarking audits to support optimisation of prescribing practice.

Medicines including controlled drugs were safely stored. The trust was planning to implement a digital solution to assist with the overview of the monitoring and recording of ward checks, including for emergency medicines and fridge temperature recording.