Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

At our last inspection we rated responsive as good. At this inspection, the rating has changed to requires improvement. We identified 1 breach of regulation. The service did not always meet the national standard for assessments within 4 hours for very urgent referrals. However, staff supported people with activities outside of the service. The service met the needs of all people. Staff helped people with communication and provided person-centred care. The service treated concerns and complaints seriously, investigated them and learned lessons from the result.

Requires Improvement: This meant people’s needs were not always met through good organisation and delivery.

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 service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

The crisis resolution and home treatment teams met the needs of the people who used their service. Care and treatment plans were completed in collaboration with people who used the service following a comprehensive, holistic assessment. Relatives and carers were able to input into care plans when the person who used the service consented.

Staff were aware of people’s individual needs and preferences and could adapt care and treatment around them, for example visiting at specific times of the day or meeting within the community rather than at home. Staff helped people with their social issues, such as homelessness and access to other services, including physical health care.

The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Staff worked in partnership with third sector organisations which provided support to people whose mental health may be deteriorating or required extra support with a view to preventing a crisis.

When people were open to other teams, staff worked closely with those staff to ensure continuity of care wherever possible. This included teams internal to the trust and external services.

The crisis teams ensured that families and carers had opportunities to be involved in the care and treatment of the people who used their services, with their consent. Staff captured carers’ engagement and needs and recorded this information in the electronic care record. Carers and families we spoke with said they felt involved and informed about their loved one’s care and treatment. All the teams had a carers lead who liaised with carers and signposted them to other agencies, such as the local authority for a carer’s assessment. The service referred to third party providers to provide additional support such as advice, guidance and signposting for unpaid carers when required.

Staff had access to the trust’s carer promise leaflets which were co-designed and developed with carers, which could be given out at assessments or visits. Staff used the Triangle of Care principles to ensure they included and listened to carers whilst providing care and treatment to their loved one. The Triangle of Care is an improvement tool based on 6 principles to ensure providers include and support unpaid carers.

Staff told us patients detained in health-based places of safety could access the multi-faith rooms on the hospital site. They also had access to religious items to ensure patient’s spiritual needs were met.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Managers made notifications to external bodies where relevant. For example, in the event of a serious incident the local commissioning services and safeguarding boards would be informed. Reviews of incidents by senior staff considered whether other external agencies needed to be involved so information and learning could be shared.

Information governance systems included confidentiality of care records. Staff received information governance and data security awareness training.

The service complied with the Accessible Information Standard which has been a legal requirement for NHS providers since 2016. The trust website for the NHS 111 option 2 service provided access for Deaf people and those with communication difficulties through a text service and a sign video. This was available 24/7 through an app. The service had received feedback from Deaf people about their difficulties using the text option when in a mental health crisis and there were plans to meet to discuss this further with a trust representative.

Staff offered people who used the service copies of their care plans and recorded when they did not want a copy. This ensured people knew their plan of care and who to contact in an emergency or crisis.

Staff ensured that people could obtain information on treatments, local services, and how to complain or provide feedback on the service. The information provided was in an accessible format. Staff told us they could produce information in different languages when required and had easy access to interpreters and signers.

Staff ensured carers and families were regularly updated about the person’s progress. For example, staff included family members in conversations about the person when they visited them at home if the person had consented.

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

From 1 December 2024 to 30 November 2025 the service received 112 complaints. Of these, 14 had been upheld and 4 were awaiting completion. In the same time period, no complaints had been referred to the Parliamentary and Health Service Ombudsman. The North Cumbria team had the highest number of complaints at 28, 7 of which were upheld. There were no specific themes or trends to these complaints. We reviewed 5 investigated complaints and saw that actions were in place when they had been upheld or partially upheld. During the same time period, the service had received 18 compliments.

People who used the service and carers told us they knew how to complain or raise concerns and were confident they would receive feedback. Staff protected people who raised concerns or complaints from discrimination and harassment.

Staff knew how to handle complaints appropriately and they received feedback on the outcome of investigations of complaints and acted on findings. Information was shared in team meetings and supervision.

People who used the service and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs dependent on their known preference such as email, text or letter. The crisis resolution and home treatment teams provided patients with QR codes at the point of discharge so they could complete a survey about their experience and provide feedback about the service. From 1 December 2024 to 30 November 2025 the service had received 644 friends and family test results. The service received an average score of 7.7 out of 10. The trust average score was 8.6.

Managers and staff had access to the feedback from people who used the service, carers and staff and used it to make improvements. Each locality held regular service user and carer involvement and experience groups to review people’s experience, listen to feedback, share good practice and provide service updates. In addition to the friends and family test, carers provided feedback in local carer forums, such as the Triangle of Care forum. Carers champions actively sought feedback and acted as an advocate when necessary to help make improvements to the service.

People who use services and carers were involved in decision-making about changes to the service. For example, in preparation for the change over of using the NHS 111 option 2 service, staff had met with people with lived experience of accessing crisis support and listened and took on their recommendations to ensure it was as seamless as possible.

The service did not always meet the national standard for assessments within 4 hours of a very urgent referral. However, staff planned discharge well which were not delayed.

The service did not always meet the national standard of 4-hours from very urgent referrals to assessment. From 1 December 2024 to 30 November 2025, average compliance for the whole service was 58%. Across the service, compliance was highest in October 2025 at 71% and lowest in February 2025 at 39%. This meant the service did not always act in a timely manner to assess and respond to the risks associated with people who used services experiencing deterioration in their mental health.

The crisis resolution and home treatment service was available 24-hours a day and was accessed through the NHS 111 option 2 telephone service which was a centralised single point of access. There were no waiting lists for the home treatment teams. From 1 June to 30 November 2025, staff mostly saw people referred urgently for a face-to-face assessment within 24 hours, and non-urgent referrals within 72 hours, in line with the trust policy. Staff made wellbeing calls to people whilst waiting for an assessment to check in with them. They could escalate the urgency of the assessment if risk had changed and increased.

Between 1 December 2024 and 30 November 2025, the 111 service took 158,438 calls. Of these, an average of 14% of all calls were abandoned. This meant that people who used the service could not always access the service.

Staff used a flow chart for Deaf callers so they could communicate with them effectively and they could access the service through a video app or text message.

Staff planned for people’s discharge, including good liaison with care co-ordinators. Staff arranged joint visits and ensured people who used services were involved in discharge planning. Staff told us they had good relationships with community mental health teams and discharge was rarely delayed.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Staff within the service and the wider organisation promoted a culture in which the people using the service felt empowered to give their views, such as people and carer forums, surveys and discharge questionnaires.

The trust supported the NHS Patient and Carer Race Equality Framework which is a mandatory anti-racism framework designed to reduce racial inequalities in mental health services. The trust had undertaken equality impact assessments of their policies and procedures to ensure they did not place vulnerable people or people with protected characteristics at a disadvantage. The trust had an equality, diversity and human rights policy in place to help ensure staff did not discriminate and instead embraced an inclusive approach to their work. Staff received training in equality and diversity.

The trust monitored health inequalities and produced an annual report. In November 2025 the trust board agreed 5 priorities for tackling health inequalities across the trust. The focus within the community teams was to increase the access to mental health support among people from marginalised backgrounds and reduce referrals through emergency and crisis pathways.

Part of the Cumbria team was involved in a pilot funded by NHS England called ‘Hope Haven’ which was 1 of 6 national pilots for 24/7 neighbourhood mental health centres. The aim was to eliminate referral and discharge processes and provide immediate needs-based support through collaboration with 6 local partners. The multiagency approach provided a wide range of support services such as health, housing, finance or substance misuse and offered short stay beds as an alternative to hospital admission. The aim was to provide more mental health support to communities without barriers and bridge the gap between services.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future.

Staff supported people who used services to make informed choices about their care and plan their future care and treatment. Staff created personalised care plans for people who used services, and accounted for their needs, wishes and feelings. Care plans we reviewed showed this and were recovery-focused.

People told us the service helped them plan what to do if their condition deteriorated and ensured they had contact details to use if this happened.

Staff ensured all relevant healthcare professionals and other relevant bodies were involved in planning the care and treatment of people with complex needs. Staff were able to refer to other teams and services if appropriate, such as drug and alcohol or physical healthcare services.