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 inspection we rated this key question as good. At this inspection the rating has remained as good. Staff assessed the physical and mental health of most people who used the service. They developed individual care plans which were reviewed regularly through multidisciplinary discussion and updated as needed. Staff provided a range of treatment and care for people based on national guidance and best practice. The teams included or had access to the full range of specialists required to meet the needs of people. Staff from different disciplines worked together as a team to benefit people who used the service. The trust had put measures in place to improve record keeping in the health-based places of safety so staff could perform their responsibilities under the Mental Health Act 1983.

Good: This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

This service scored 71 (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 made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

We reviewed 37 care records across all the crisis resolution and home treatment teams and 8 from the NHS 111 option 2 service whilst on site. Staff completed a comprehensive mental health assessment of the person referred in a timely manner. Staff completed the trust’s biopsychosocial formulation assessment to understand the person’s difficulties and risks.

Staff developed care plans that met the needs identified during assessment. Care plans were personalised, holistic and recovery-oriented and were updated whenever necessary. They were completed in collaboration with people using the service, were easy to understand and included targets and realistic goals which were time focused.

Staff assessed people’s physical health needs. The Northumberland and North Tyneside team had completed an audit between 26 June and 28 August 2025 and found that 78% of people had received baseline physical health checks. It noted an improvement since the previous audit completed in Spring 2025. Trust standards stated all people who were taken onto the team’s caseload received a physical health screening within 72 hours of assessment and staff monitored medicines with that requirement. An action plan was in place to improve compliance which included a section added to the MDT proforma to remind staff to record physical health. From the records we reviewed, staff had either completed a physical health check or reviewed results of tests that had recently been taken. For example, blood results from recent hospital admissions or tests completed by community mental health teams. The Northumberland and North Tyneside team had a physical health nurse lead who monitored and reviewed everyone’s physical health who came onto the home treatment caseload, with a view to improve compliance with physical health monitoring. Patients detained in the health-based places of safety received a physical health screening by the duty doctor.

Staff had not always performed their roles and responsibilities under the Mental Health Act 1983 correctly. Record keeping in the health-based places of safety was poor and essential information was often missing and not all patients were assessed within 24 hours in health-based places of safety. However measures had been put in place to make improvements. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Staff provided a range of care and treatment interventions suitable for people who used the service. The interventions delivered were those recommended by and were in line with guidance from the National Institute for Health and Care Excellence (NICE). They included psychological therapies, for example, solution focused interventions and dialectical behaviour therapy (DBT). The trust used quality metrics for self-harm and suicide based upon NICE guidance which included staff training, risk assessments, engagement, psychological interventions and collaboratively developed care plans. Other interventions offered were medication, physical health monitoring, psychoeducation and safety planning.

Staff ensured that people had good access to physical healthcare and liaised with GPs regarding referrals to specialists when needed. Staff had access to primary care notes when required.

Staff participated in clinical audit, benchmarking and quality improvement initiatives. The trust had implemented a 4 month audit cycle. At the time of our inspection, audits included under 18s being held in a HBPoS, physical and public health, healthcare records quality monitoring tool, and care planning and personalisation. Results showed there were minor areas of concern in all 4 areas and action plans were in place to make improvements.

The team included or had access to the full range of specialists required to meet the needs of people who used the service. As well as doctors and nurses, there were occupational therapists, clinical psychologists, social workers, pharmacists and peer support workers. Staff were experienced and qualified and had the right skills and knowledge to meet the needs of the patient group.

Managers ensured that staff had access to regular team meetings. We reviewed team meeting minutes and saw there was a comprehensive standard agenda that included information to keep staff up to date with team performance and trust updates.

Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge, including specialist training. Staff could attend training courses that would benefit them and teams were provided with regular bitesize training. Some staff told us of training they were attending to enhance their skills.

Managers told us they dealt with poor staff performance promptly and effectively. They were supported by human resources.

Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles. The trust had relevant policies and procedures that reflected the most recent guidance and staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice. Staff received combined training in the Mental Health Act, Mental Capacity Act and Deprivation of Liberties Safeguards. At the time of our inspection, 81% of staff across the service were compliant.

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. Regular reports were provided for assurance to the Mental Health Legislation steering group which in turn reported to the Mental Health Legislation committee. The Mental Health Legislation steering group had been made aware of the challenges experienced with the current configuration of HBPoS provision across the trust. This included the ability of staff to manage the suites as part of the crisis service provision and the challenge around safety and risk of injury to staff.

Staff did regular audits to ensure that the Mental Health Act was being applied correctly and there was evidence of learning from those audits. The latest audit dated 28 November 2025 looked at 138 section 135 and 136 detentions between 1 April and 31 July 2025 and found that action was required to ensure patients always had their rights explained to them and record keeping was improved. Out of 138 patients, 63% had been given their rights, 7% had not been given their rights, 28% of forms were left blank or marked as not applicable. The audit also reviewed whether patients had been assessed within 3 hours of arrival which was good practice; 50% had not been and 12% of forms did not record any assessment time. This meant only 38% of assessments had been commenced within 3 hours. Other findings showed that 10% did not have the decision from the assessment recorded. The trust had an action plan in place, and the audit was due to be completed again in June 2026 however we informed the trust of our concerns following our inspection. The trust sent us an improvement plan with actions that included a review of the audit tool, an updated section 136 form in the electronic care record system, reminders to staff of the importance to fully complete records and sample random record audits to ensure compliance. From the records we reviewed on site we found 1 form out of 9 had missing information.

The trust’s Mental Health Act office provided a HBPoS activity and compliance report. From June to October 2025, 225 patients were detained under section 136. During this time, the trust reported 29 breaches of the 24-hour timeframe which equated to 13%, although 43 records did not have any time recorded so this figure could be higher. Most breaches were due to unavailability of acute beds within or outside the trust.

We reviewed 9 records of patients being held under section 136 in the health-based places of safety. We found that staff explained patients’ rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done it. Patients we spoke with confirmed they had their rights explained to them.

Staff stored copies of patients' detention papers and associated records correctly and so that they were available to all staff that needed access to them.

The service worked well with other teams to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff held weekly multidisciplinary meetings to discuss and review care, treatment, progress and discharge planning. These were attended by the full range of disciplines including nurses, doctors, support workers, pharmacists, peer support workers, psychologists and social workers. Each team held a daily morning meeting to review risk and plan and allocate tasks for the day. We attended morning meetings across all of the teams. We found they were organised and well attended. Items discussed included assessments completed over the last 24 hours, pending assessments, people who staff had concerns about, and tasks for the day.

Staff shared information about people using the service at effective handover meetings within the team at least twice a day. Shift coordinators ensured tasks for the day were allocated and managed and planned assessments, home visits and monitored progress throughout the day including outstanding work to be completed.

The teams had effective working relationships, including good handovers, with other relevant teams within the organisation. Each team held a weekly meeting with the community mental health teams and arranged face to face transfers of care with care coordinators or other key staff. Discharge facilitators attended ward reviews to ensure people were offered home based care and treatment as soon as possible.

The trust had identified that people were still being looked after on in-patient wards when they were clinically ready for discharge. Therefore the ‘hospital 2 home’ model was developed to move people from in-patient wards to home treatment quicker and reduce delayed transfers of care. Staff from the crisis teams worked in collaboration with internal and external colleagues to move people through the pathway in a safe, person-centred way.

Internal quality processes had identified that the interface and pathway between the crisis and home treatment teams and the community mental health teams required improvement. Therefore, weekly interface meetings had been implemented to improve communication and ensure people were safely and effectively transitioned between services.

The teams had effective working relationships with teams outside the organisation such as primary care and social services. Staff liaised with external agencies when required such as GPs and local authority safeguarding teams. Staff provided information such as admission and discharge summaries and attended external meetings when required to discuss and review care.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff supported people to live healthier lives. Staff completed lifestyle reviews which included discussions about healthy eating, smoking, substance misuse and provided advice about living a healthy life. The service referred people to external organisations such as substance misuse services when required.

The Northumberland and North Tyneside team had a physical health nurse lead who monitored and reviewed everyone’s physical health who came onto the home treatment caseload. They attended multidisciplinary meetings, completed tasks such as ECGs and blood tests, undertook physical health audits and liaised with other health care professionals such as GPs or hospital consultants. They reviewed care records for physical health monitoring and reminded staff of tasks that required completion. The Newcastle and Gateshead team had a support worker who completed some physical health tasks. The other 2 teams did not have a dedicated physical health worker.

People who were prescribed medicines and those who were starting antipsychotics received a physical health check which included blood tests, an electrocardiogram (ECG) and observations such as weight and BMI, pulse and blood pressure. The Northumberland and North Tyneside team had seen improvements had been made when they re-audited completion of physical health standards from the Spring to the Summer in 2025.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Staff used recognised rating scales to assess and record severity and outcomes, such as the Health of the Nation Outcome Scales. Nursing staff used side effect monitoring tools to monitor side effects of anti-psychotic medicines.

Staff used technology to support people effectively. All staff had access to a trust laptop and mobile phone. They could access the trust’s electronic record system easily and some electronic notes systems from other agencies. Physical health results could be accessed online quickly. Staff utilised technology to communicate quickly and easily with both internal and external teams which was used effectively within multidisciplinary and risk meetings.

The trust told us they did not complete outcome measure audits apart from reviews of care records and response times.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff took all practical steps to enable people who used the service to make their own decisions. If a person’s capacity was deemed to be lacking then staff considered other options such as a Mental Health Act assessment. This was discussed within the multidisciplinary team.

Across the crisis resolution and home treatment teams staff assessed and recorded capacity to consent appropriately. Capacity to consent was considered at each initial assessment when people were admitted to the crisis service to ensure they understood and agreed to the care and treatment provided. We saw this reflected in care records and observed staff reviewing and discussing capacity in multidisciplinary meetings. Staff ensured patients could access advocacy when required who could offer advice and support.

Staff had a good understanding of the Mental Capacity Act. Staff received combined training in the Mental Health Act, Mental Capacity Act and Deprivation of Liberties Safeguards. At the time of our inspection, 81% of staff across the service were compliant.

The trust 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 trust regarding the Mental Capacity Act, including Deprivation of Liberties Safeguards.