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.

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 regulation for, people’s safe care and treatment, safeguarding and safe staffing.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 2. The evidence showed some shortfalls. The service did not always have a proactive and positive culture of safety. They reported but did not always thoroughly investigate safety events. Lessons were not always learnt to continually identify and embed good practice.

There had been no serious incidents in the service in the last 12 months. We reviewed 8 significant incidents, which covered a range of issues including self harm, instances of mechanical restraint and young people going absent without official leave (AWOL) from the service.

Action to mitigate the risk of incidents was not always effective. For example, we reviewed an incident where a young person had accessed the roof. This incident was investigated thoroughly and a range of actions were taken to reduce the likelihood of an incident recurring, including environmental improvements to prevent young people from accessing this space and actions to ensure staff were prepared in the event of another incident. However, we were told there had been several other instances of young people accessing the roof. It was therefore unclear whether incidents were fully responded to at the earliest opportunity.

All staff knew what incidents to report and how to report them and staff reported all incidents that they should report. However, it was not clear if incidents were reported in line with national guidance. The trust’s incident policy contained guidance on categorising levels of harm which was taken from national guidance. However, there were significant amendments which meant the policy deviated from national guidance. For example, the trust had removed ‘not needing immediate lifesaving intervention’ from the definition of moderate harm. This meant that incidents where young people requiring lifesaving interventions such as actions to prevent them from choking were regularly categorised as low harm. In addition to this guidance about the categories for psychological harm had not been included in the policy.

Staff understood the duty of candour. They were open and transparent and gave young people and their families a full explanation if and when things went wrong. There were no statutory duty of candour reports made within the service in the last 12 months. However, there was evidence of staff apologising when things had gone wrong.

Staff received feedback from investigation of incidents, both internal and external to the service and met to discuss that feedback. There was evidence that changes had been made as a result of feedback. Lessons learnt were discussed in team meetings with staff and there was also a trust learning and improvement group. Staff were debriefed and received support after a serious incident.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the young person was received to determine if their needs could safely be met.

Staff did not always involve all the necessary healthcare and social care services to ensure young people had continuity of safe care, both within the service and post-discharge. Stakeholders raised some concerns about communication including concerns about there being gaps in aftercare planning. For example, staff did not involve adult social care in a decision about a young person’s treatment. This was particularly concerning because they were directly responsible for the young person’s welfare at the time of the incident.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They concentrated on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. However, they did not always share concerns quickly and appropriately.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. However, they did not always work effectively with other agencies when safeguarding concerns were identified.

Staff did not always raise safeguarding concerns, when appropriate. Staff had raised 54 safeguarding referrals in the 6 months prior to our inspection. Of these, staff on Fraser ward had raised 4 safeguarding referrals and staff on Stephenson ward had raised 1 safeguarding referral. We reviewed 8 incident reports, of these 3 incidents on Stephenson ward and 2 on Fraser met the threshold for reporting to the local authority, according to the provider’s safeguarding children’s policy. This had not appeared to take place. The incident reports recorded that only 1 of the incidents had been shared with the local authority and this was in relation to external concerns. In addition, staff had not shared significant information about a young person’s treatment with the local authority when they were acting in place of the parent for the young person.

Staff had received safeguarding training, and the service had a safeguarding adults and safeguarding children policy which were in date and a range of accompanying documents which provided safeguarding guidance for staff. However, the system for reporting safeguarding was complicated, because the trust worked with 12 local authorities each with their own thresholds and guidance. The trust had produced a document with links to reporting for each of the local authorities, however these mainly led to local authority websites and did not provide a clear guidance for staff to follow in the event of safeguarding concerns. Staff received weekly safeguarding supervision and followed safe procedures for children visiting the service.

Mental Capacity Act

64% of staff had had training in the Mental Capacity Act. However, staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles.

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 young people to make their own decisions. For those who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions. When young people lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. There was evidence of decision specific best interests’ decisions being made in young people’s records.

Staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it.

We scored the service as 2. The evidence showed some shortfalls. The service worked well with people to understand and manage risks. However, they did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 12 risk assessments / risk management plans during the inspection. Staff completed risk assessments for all young people and updated them when required.

Staff carried out 2951 episodes of restraint in the 12 months prior to our inspection. Of these 2781 were low levels of restraint. Low level restraints are usually interventions where service users are guided, however this was not detailed within the provider’s policy. There was a high level of prone restraint in the service with 148 incidences of prone restraint carried out in the 12 months prior to our inspection. Of these, 91 were on The Riding. Prone restraint is where a person is held face down and is high risk because it can impact on a person’s breathing. We reviewed the last 10 incidents of prone restraint. The longest of these lasted for 8 minutes. There was a downward trajectory for levels of prone restraint over the last year. Reviews of incidents did not include a review on the application of prone restraint.

Staff carried out 21 incidents of mechanical restraints in the last 12 months. Mechanical restraint was carried out 18 times on Stephenson ward, twice on the Riding and once on Fraser ward which was particularly concerning, as this ward was for young autistic people or young people with a learning disability and supported very vulnerable children and young people. The National Institute for Health and Care Excellence (NICE) guidance sets out very specific and limited circumstances, where mechanical restraint should be used on young people. The guidance states that mechanical restraint should only be used when transferring young people between medium secure and high secure settings or in certain circumstances in high secure settings. This was not reflected within the provider’s policy and the policy did not contain sufficient information regarding mechanical restraint carried out on children and young people. None of the incidents where mechanical restraint was used were in line with NICE guidance. The trust produced a 7-minute briefing on mechanical restraint but this did not mention mechanical restraint on children. The trust had recognised the impact of mechanical and prone restraint on young people and from October 2024 signed up too an ambition for zero use of mechanical and prone restraint within 12 months. In the interim, mechanical restraint could only be used following the approval of a group director and mechanical restraint was ceased across The Riding, Redburn ward and Fraser ward in October 2024. Staff and patients received debriefs following incidents of mechanical restraint.

Staff administered rapid tranquilisation on 46 occasions in the 12 months prior to our inspection. We reviewed 7 instances of rapid tranquilisation for 1 young person. Staff had opened a care plan for these and de-escalation techniques were used. However, there were some gaps in physical health monitoring following rapid tranquilisation administration.

Seclusion levels on some wards were high. There were 145 episodes of seclusion in the 12 months prior to our inspection, including 54 episodes of seclusion on The Riding and 45 episodes of seclusion on Fraser ward. There were 5 episodes of seclusion on Lotus ward and none since January 2025. Lotus ward was working towards de-commissioning their seclusion room. There had been 2 episodes of long-term segregation in the 12 months prior to our inspection. Appropriate actions were taken to review these and the trust had commissioned an external review of long-term segregation for one of the young people and an independent care education and treatment review had taken place.

Staff involved young people in care planning and risk assessment, and this was evidenced within young people’s care documentation. Staff communicated with young people so that they understood their care and treatment, including finding effective ways to communicate with young people with communication difficulties. However, most young people told us they were not aware of the content of their care plans and some young people were not aware they had a care plan, which suggested that care plans were not presented to young people in a way that was accessible to them.

Staff enabled young people to give feedback on the service they received, for example, via community meetings or feedback forms. Young people felt able to feedback concerns, particularly via peer supporters but sometimes felt this did not result in any action. Staff also ensured that young people could access advocacy.

We scored the service as 1. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. However, staff made sure equipment and technology supported the delivery of safe care.

Staff did not always carry out regular risk assessments of the care environment. Staff had daily lists of jobs but these were not always completed, for example we found the perimeter check on Lotus ward had not always been carried out and environmental checks of the courtyards and checks that external gates had been locked had not always been carried out on Fraser ward.

Fire risk assessments had been completed for the wards and contained action plans for outstanding issues. The fire risk assessment stated that personal emergency evacuation plans (PEEPs) would be developed as necessary. We found these were not always in place, for example, there were young people on Fraser ward who had complex needs and may have struggled to follow direction in the event of a fire and there were young people in long term segregation, where careful planning would be needed to ensure they could be supported to evacuate safely.

The ward layout did not always allow staff to observe all parts of ward. We found blind spots on Lotus ward, Stephenson ward and Fraser ward that were unmitigated and there were potential ligature anchor points on the wards. The trust carried out a Clinical Environmental Risk assessment (CERA), which identified risk areas, and actions that were taken to mitigate these risks. This demonstrated that wards had some anti ligature measures in place such as collapsable curtain rails, door top alarms and anti-ligature fixtures in bathrooms. However, full ligature risk assessments had not been carried out for each ward. This meant that higher risk areas and mitigation actions for these were not systematically identified and shared with staff. For example, the visitors room on Lotus ward had drawer handles that could be used as a potential ligature risk, areas of the grounds had railings, and the legs on chairs could be used to ligature. These were not recorded on the Clinical Environmental Risk assessment as a risk to young people and recorded mitigations were not in place. Most staff we spoke with were aware of some but not all ligature points. Riding ward was piloting a new ligature risk assessment which included a ligature heat map for identifying high risk areas.

Staff had easy access to alarms and young people had easy access to nurse call systems.

All wards contained seclusion rooms, although Lotus ward had not used their seclusion room since January 2025 and were working towards decommissioning it. Seclusion rooms met national specifications. They mostly allowed clear observation, there was some blind spots and these were either covered by mirrors or could be monitored via CCTV. They had two-way communication, toilet facilities, a clock and some had access to a courtyard. The level of natural light in some of the seclusion rooms was poor and the rooms were dark, particularly on Fraser ward.

Clinic rooms were clean and tidy and were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. However, staff worked together well to provide safe care that met people’s individual needs.

Vacancies were low with most wards over their established numbers. The average turnover was 3.9% across the 5 wards and sickness absence in the last 12 months was 7.3%.

The service used 1317 agency staff shifts and 1075 bank staff shifts in the 3 months prior to our inspection. Staff told us that this could be challenging for some of the young people, particularly those on the ward for young people with a learning disability who needed a familiar staff team. Managers told us they block booked agency staff where possible to help ensure young people had a team who were familiar to them. When agency and bank nursing staff were used, they received an induction.

Managers had calculated the number and grade of nurses and healthcare assistants required. The number of nurses and healthcare assistants matched this number on all shifts. Staff carried out daily huddles to review staffing and the ward manager could adjust staffing levels daily to take account of case mix.

A qualified nurse was present on the ward at all times and staffing levels allowed young people to have regular one-to-one time with their named nurse. Staff told us that shortages occasionally resulted in staff cancelling escorted leave or ward activities. There were enough staff to carry out physical interventions safely and staff had been trained to do so. Training compliance for PMVA training was 71%. There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency.

Staff were not up to date with all of their mandatory training. For example, compliance for MHA/MCA DoLS was 64%, compliance for clinical supervision was 52% and compliance for autism was 27% and learning disability was 22%. This was particularly concerning as wards had young people with autism and Fraser ward was a ward for autistic young people and young people with a learning disability. The compliance for Fraser ward was 39% for learning disability training and 19.5% for autism training. This meant we were not assured that staff had the knowledge and skills to meet the needs of the young people they were caring for. Training in resuscitation was also low for Fraser ward with resuscitation level 2 paediatric training being at 49% and resuscitation level 3 immediate life support at 67%. It was not clear what mitigations were in place to address this. The range of training was appropriate for the patient group using the service and 77% of nurses on Fraser ward were specialist learning disability nurses.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date. Ward areas were clean, had good furnishings and were well-maintained.

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 carried out an infection prevention and control audit on each ward with accompanying action plans for issues identified.

We scored the service as 4. The evidence showed an exceptional standard. The pharmacy service had a strong, proactive and positive culture of safety, based on openness and complete honesty. They actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

Staff followed good practice in medicines management and did it in line with national guidance. Clinic rooms were clean and tidy, and medicines were stored appropriately.

Medicines reconciliation figures provided showed that 89% of people admitted to the service had a medicines reconciliation completed within 24 hours and 100% had one completed within 72 hours. In May 2025 80% of people who were discharged from the service were referred to the Discharge Medicines Service which supported people on their transition to community pharmacy. Staff described how at discharge training was provided to families and carers on how to use the medicines safely to help with the transition out of the hospital setting.

Staff carried out medication audits including annual controlled drugs audits and took part in national POMHUK audits for benchmarking. In addition, the team had also taken part in a national prescribing benchmarking programme where they had performed similarly to other units of the same type in the country.

A digital flag was in place and accessible to pharmacy staff to help early identification of people with a learning disability and or autistic people. Staff described a variety of tools and resources available to support people with understanding, taking and getting the most out of their medicines. Emphasis was placed on individualising the information provided, taking into account literacy abilities as well as retention of information and how tools such as pictograms and repetition supported people to understand their medicines.

Pharmacy staff were embedded in the multidisciplinary team (MDT) and demonstrated an advanced following of STOMP/STAMP principles. Working holistically with the MDT, parents and the person a series of data charts had been developed to subjectively review and track the impact changes made by the multidisciplinary team had on people within the service. This made for an agile and responsive assessment factoring in not only medical but psychological and environmental factors to give an in-depth oversight of the impact changes had made. For example, we saw how one person’s medicines had impacted on their ability to access education on the morning, through the use of the charts this had been tracked and proactive changes made to improve the persons outcomes. The charts had also identified patterns in behaviours which by collaborative working had facilitated staff supporting people better and reducing the amount and types of medicines used. We looked at three peoples records and each person through engagement with their families and themselves had their medicines significantly reduced and therefore their prescription optimised to enable better outcomes.

Physical health was monitored in collaboration with a local GP service. Staff described many interactions with positive outcomes for people including one person whose medicines had been initiated then changed due to sensory and taste intolerances. Skin conditions were also being managed collaboratively between the person and staff. The whole person approach which included the pharmacy team and the impact of medicines meant that areas such as hormonal changes and weight management were proactively discussed and reviewed. Changes and additions of medicines were introduced slowly and in a holistic approach with weekly prescribing reviews. A standard operating procedure had been developed to assist with the process and recording of the prescribing reviews this had ensured that all necessary details were captured in a structured and comprehensive way.

Pharmacy staff had engaged with speech and language staff to use talking mats to support people with side effect profiles, the use of visual boards had increased the communication around side effects and ensured that the persons experiences were an integral part of decision making.