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 inspection we rated this key question as good. At this inspection the rating has changed to requires improvement. We identified 2 breaches of regulation. Staff were not always up to date with their training needs. Patients in 2 out of the 4 health-based places of safety did not always have access to outside space or fresh air.

However, environments were clean, tidy and well-maintained and systems were in place to support the delivery of safe care and staff received regular supervision. Staff assessed and managed risks to people who used services and themselves well. Staff understood how to protect people from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

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.

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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The trust had policies and procedures in place and staff knew what incidents to report and how to report them. Managers had access to comprehensive dashboards which provided detail in real time for action, analysis and thematic reviews. When identified through initial analysis, incidents that met the criteria for further investigation were reviewed using the NHS Patient Safety Incident Response Framework (PSIRF). PSIRF is the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. In the 12 months prior to our inspection there had been 1 patient safety incident investigation related to the Northumberland and North Tyneside team which incorporated 2 incidents. Specific learning points for the team included consideration of risk to carers, recording of clinical discussions, staff to always fully complete paperwork and clearly identify tasks. Managers shared learning from incidents with the whole team. Staff had access to regular local learning lessons forums.

From 1 September to 30 November 2025 there were 1167 incidents across the crisis resolution and home treatment service. All were categorised as no or low physical harm apart from 3 moderate physical harm and 1 severe physical harm. There had been 5 deaths of people who were open to the service. From the same time period there were 64 incidents across the health-based places of safety. None were categorised as higher than low physical harm. There had not been any never events or Prevention of Future Deaths reports within the crisis resolution services in the past 12 months. A never event is a serious, largely preventable patient safety incident that should not occur if available preventative measures are implemented.

The trust reviewed any deaths at mortality review panels and documented findings within the trust wide template. Actions and learning would be disseminated to the teams through team meetings and supervision. From 1 June to 30 November 2025 there had not been any mortality reviews for the crisis resolution service.

Staff received feedback from investigation of incidents, both internal and external to the service through regular team meetings and supervision and staff met to discuss that feedback. Staff gave examples of changes that had been made as a result of feedback and learning. For example, learning from a death strengthened communication with GPs when certain medicines had been prescribed and risks highlighted. Staff told us they were debriefed and received support after serious incidents.

Staff understood the duty of candour. They were open and transparent and gave people who used services and families a full explanation if and when things went wrong. From 1 December 2024 to 30 November 2025, there was one incident that met the duty of candour threshold.

Staff from the crisis resolution and home treatment teams were responsible for managing and co-ordinating care for patients detained in the health-based places of safety (HBPoS). Staff across the service told us they had concerns and anxieties about working within the HBPoS due to past incidents of aggression towards them and previous staff injuries. From 1 April 2024 to 30 June 2025 there had been 251 incidents involving 127 people who had been detained. Of these, 85 incidents were related to aggression and violence and 71 incidents were directed towards staff, of which 25 resulted in actual bodily harm and 2 resulted in moderate harm. Trust data showed there had been an increase in incidents year on year. Aggression and violence accounted for 34% of all incidents in the HBPoS and was by far the highest reported incident. Managers and leaders were aware of staff concerns and senior managers had considered other options regarding the current HBPoS model but no firm agreement had been made at the time of our inspection.

Staff across all sites had access to an appropriate alarm system. All of the HBPoS were adjacent to in-patient wards and ward staff would be alerted when an alarm was activated and could quickly attend and manage the situation.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service had a clear criteria of who they offered a service to. The crisis resolution and home treatment teams were known as ‘universal crisis teams’ and were split into 3: younger people, working age adults and older people. The health-based places of safety accepted referrals for people of all ages.

The service’s referral and admission processes ensured that all essential information about the person was received to determine if their needs could safely be met. Staff from the NHS 111 option 2 service provided an initial triage of all referrals over the telephone to determine whether a full assessment was required. Staff would signpost people to other services if they were not in a crisis, such as third sector organisations.

Staff said caseloads varied and at times the workload felt unsustainable, which was also impacted by staff sickness and when staff had to work in the health-based place of safety. Managers discussed and reviewed caseload size and workload in governance meetings. At the time of our inspection, crisis resolution and home treatment teams caseloads ranged from 44 in Newcastle and Gateshead and up to 84 in North Cumbria.

Staff reviewed essential safety and risk information about people who used services at least twice a day in multidisciplinary meetings. These meetings included plans to safely meet people’s needs and discharge planning. We observed 5 meetings and saw robust discussions of completed and planned assessments, home visits, and physical health and safeguarding needs for people on the team caseload. Staff demonstrated a good understanding of each person’s risks and planned care and treatment well. Shift coordinators oversaw all tasks, allocated work and monitored waiting times for assessments.

Staff adhered to the trust’s non-attendance policy which gave people the opportunity to engage with the service if they missed an appointment, were not brought or were not at home when staff visited. The policy provided a framework for staff to follow based upon risk which included contacting the person and GP and discussing next steps as part of the multidisciplinary team. The trust had processes in place to remind people of their appointments such as text messaging to help prevent missed appointments or visits. The ‘promoting engagement with service users’ policy guided staff in how to proactively engage people who disengaged with the service or found it difficult to engage.

The service used a team caseload approach and staff could clearly identify people who were at high risk and who required more intensive support through visual zoning systems. Visits would be increased quickly or decreased according to people’s individual needs and in conjunction with multidisciplinary reviews and discussions.

Staff involved all the necessary healthcare, social care and third sector services to ensure people had continuity of safe care, both within the service and post-discharge. Staff liaised with community teams when people were seen by both community services and crisis teams and involved them in discharge planning. Staff referred to community teams when appropriate and facilitated joint working.

The trust had highlighted that there had been an increase in section 136 detentions since the introduction of Right Care, Right Person. Right Care, Right Person is a national approach to make sure people who have mental health needs get help from the correct service. This meant teams workloads had increased due to the requirement to work within the health-based places of safety when the police brought a detained patient.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were trained in safeguarding adults and children, and knew how to make a safeguarding referral, and did so when appropriate. From 1 September to 30 November 2025, the service had reported 326 safeguarding concerns overall, with 78 being further referred to the local authority.

At the time of our inspection, 98% of staff were compliant in safeguarding training for adults and 92% were compliant for safeguarding children up to level 2. However, compliance was lower for level 3 at 65% for adults and 69% for children.

Staff from the crisis resolution and home treatment teams understood how to protect people from abuse and worked well with other agencies to do so. Staff told us they could access support from the trust’s safeguarding team when they needed to and knew who to contact when they needed advice. Policies and procedures were in place to support staff when referring to other teams or agencies when required. Staff worked well with other agencies such as the police to safeguard people and reported good working relationships with local authority safeguarding teams. The trust were represented at multi-agency safeguarding meetings.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. We observed staff identifying and discussing safeguarding concerns during multidisciplinary meetings. Staff recorded any safeguarding issues or concerns in the electronic care record. When children were living in the same house staff made safeguarding referrals. Managers had oversight of all safeguarding concerns and monitored them through the trust’s incident reporting system. Any learning was disseminated to staff through team meetings, supervision or learning forums.

The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to people and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff in the health-based places of safety used restraint and seclusion only after attempts at de-escalation had failed. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 29 risk assessments and risk management plans across all the crisis resolution and home treatment teams, 8 from the NHS 111 option 2 service and 9 from the health-based places of safety. The trust used a structured, person-centred framework to collaboratively understand a person’s difficulties and risks. Risk assessments were completed to a good level, updated regularly and appropriate risk management plans were in place. In October 2024, the trust launched an enhanced Clinical Risk and Suicide Prevention training package. This was co-produced with people with lived experience.

Staff involved people who used the service and their family members or carers in care planning and risk assessments. Electronic care records showed co-production of planning care and treatment between staff, the person using the service and with consent, their family members or carers. Care plans were offered to the person using services, including details of how to contact services when needed or what to do if risk factors escalated. Managers completed regular audits on care records and shared results with teams and specific individuals when improvements were required.

Staff communicated with people who used services so they understood their care and treatment, including finding effective ways to communicate when people had communication difficulties. Staff ensured people could access advocacy when required.

Staff enabled people to give feedback on the service they received. The crisis resolution and home treatment teams provided people with a QR code and a link on their discharge letters so they could easily complete a ‘Your Voice’ survey anonymously about their experience and provide feedback about the service.

From 11 December 2024 to 25 November 2025 staff had been injured on 18 occasions in the health-based places of safety (HBPoS). There were 5 occasions when staff were either spat at or bitten, and several occasions when staff were punched when patients had become distressed and agitated.

From 1 June to 30 November 2025 there were 17 restraints in the health-based places of safety. Of these, 12 were due to threatening or aggressive behaviour to staff or other. Crisis resolution staff staffed the HBPoS and staff from the adjacent in-patient wards attended the suites when alarms were activated. Crisis resolution staff told us they often felt vulnerable and anxious when looking after a person in the HBPoS, due to past incidents and staff injuries. Crisis resolution staff were not required to undertake Prevention and Management of Violence and Aggression (PMVA) training; this was mandatory for in-patient staff only. PMVA training was used as an approach to handle challenging behaviours safely, focusing on de-escalation and using physical intervention as a last resort. Staff would be equipped to recognise warning signs, defuse tension and manage incidents while prioritising safety and reducing restrictive practices. We received mixed opinions as to whether crisis resolution staff thought PMVA training would be beneficial for them. Some said they would like to have the training while others thought it may put them at a greater risk. However, breakaway training was mandatory for staff who worked within the HBPoS. This was as a result of staff feedback and included de-escalation techniques and approaches to help someone in a mental health crisis.

Patients in 2 out of the 4 health-based places of safety did not always have access to outside space or fresh air. However, environments were clean, tidy and well-maintained and systems were in place to support the delivery of safe care.

Staff visited most people at home however some of the teams also saw people in one of the consultation rooms on site. Consultation rooms were clean, tidy, had good furnishings, and allowed privacy. Waiting areas were well-maintained and overseen by reception staff. The rooms had alarm call systems and staff carried personal alarms.

Clinic rooms were fully equipped with accessible resuscitation equipment that staff checked regularly. Staff checked equipment and temperatures daily.

The health-based places of safety (HBPoS) were clean and well-maintained. Staff did regular environmental risk assessments of the HBPoS. Staff had mitigated the risks of any potential ligature anchor points and action plans were in place when concerns had been identified. The layouts allowed staff to observe all parts of the suite. There was closed-circuit television (CCTV) which allowed staff to observe internal and external patient areas.

Police carried out personal searches of patients before they entered the health-based places of safety. Any items deemed to be a risk were held in storage. Staff had access to a safe in the nursing office to keep items safe.

Most of the HBPoS had been adapted for use from rooms that were previously used for other purposes. For example, the HBPoS at St George’s Park had previously been a seclusion room at the back of an acute ward and was small. It did not have a staff toilet. Patients detained in HBPoS at Hopewood Park and St George’s Park had no access to outside space and fresh air. The trust had proposed a new HBPoS model which would consist of a dedicated staff team and 4 purpose built suites across 2 hospital sites. However, the proposal had not been agreed by the board due to quoted building costs which exceeded the available project budget.

The teams mostly had enough staff to safely manage the service, although when the health-based places of safety were busy, staff did not always feel there were enough. Staff were not always up to date with their training needs. However, staff received regular supervision and were experienced and skilled.

As of 30 November 2025,team establishments were: Newcastle and Gateshead had 59.6 whole time equivalent (WTE) staff; North Cumbria, 79.3 WTE staff; Northumberland and North Tyneside, 70.1 WTE staff; Sunderland and South Tyneside, 60.4 WTE staff and the NHS 111 option 2 service had 57.5 WTE staff.

As of 30 November 2025, there were a total of 26.1 WTE staff vacancies across the service, which equated to 8% of the team establishments. These were highest in the North Cumbria teams at 11.6. This was followed by the NHS 111 option 2 service with a vacancy rate of 9.5 with 8 being for call handlers. The lowest vacancies were in the Northumberland and North Tyneside team and the Sunderland and South Tyneside team at 1 vacancy each. Overall staffing had been identified as a risk in the North Cumbria team and had been on the risk register since 2021 and rated as high risk despite mitigations being in place. Managers told us it was difficult to recruit to the region due to the rural geography, an aging population and the lack of incentives compared to neighbouring trusts and providers.

From 1 December 2024 to 30 November 2025, average sickness absence for the whole service was above the trust target of 5%. The team with the highest sickness absence was the initial response team within Newcastle and Gateshead at 23%; the lowest was the crisis response and home treatment team in Sunderland and South Tyneside at 7.3%. Within the same time period, the overall trust sickness rate was 6.8%.

From 1 December 2024 to 30 November 2025 the average staff turnover for the whole service was below the trust target of 10%.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. When agency and bank nursing staff were used, those staff received an induction and were familiar with the service. From 1 September to 30 November 2025 agency and bank staff were used 1544 times. There were 133 times when shifts could not be filled.

Most staff said there was enough staff to complete assessments and home treatment based tasks, however this was not always the case when a person was admitted to the health-based place of safety (HBPoS). Minimum staffing for the HBPoS was 1 qualified nurse and 1 support worker. Staff from the crisis resolution teams were responsible for managing the HBPoS although this could not be pre-planned due to the unpredictability of knowing when a person would be brought in by the police. Staff told us this put pressure on them and could delay other work as the section 136 assessment took priority. From 30 November 2024 to 1 December 2025, there were 16 times when assessments or visits were delayed while staff were undertaking a Section 136 assessment, which equated to less than 1% of all crisis contacts. The concerns had been escalated and managers had put mitigations in place such as senior staff were available to provide input to reduce the risk however staff said this was their biggest worry.

Managers could adjust staffing levels daily to take account of case mix. There was adequate medical cover for most teams in the day and an on-call system was deployed at night.

Staff in the North Cumbria team said there was an imbalance of medical cover between the East and the West of the region. The East region had more medical staff and managers acknowledged that there was a disparity between the 2 regions, however recent recruitment would improve coverage in the West. At times staff undertook desktop medical reviews rather than face to face, however this had not impacted on the person’s care.

Staff received appropriate mandatory training which was comprehensive and met the needs of staff and people who used services. Most staff were up to date with their training needs although there were lower levels of compliance across the service for some courses. Overall compliance for autism core capabilities was at 48%, learning disability tier 1 was 38%, safeguarding adults and children level 3 were 65% and 69% respectively. The trust told us at the time of our inspection, that staff were expected to be trained in level 2 adult basic life support training only. However, learning from an incident highlighted that staff required level 3 resuscitation training, therefore it had recently been introduced as required learning and a completion date of 31 March 2026 had been set.

Managers provided staff with supervision. The trust policy stated that staff should receive management supervision as a minimum once every 3 months and clinical supervision monthly or bi-monthly, dependent on their role. As of 30 November 2025, staff who had received regular managerial supervision was 82% and clinical supervision was 74%. Managers and staff could also attend reflective practice sessions to discuss a specific case or incident.

Managers provided new staff with an appropriate induction. New starters would attend a trust wide induction and received a local induction with their supervisor.

Most of the teams had peer support workers. A peer support worker is someone who has lived experience and works with individuals and represents the voices of people who use the service and carers in forums. They also collected and shared feedback to help shape service design and delivery within the trust. They received regular supervision.

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.

We looked at clinic rooms, consultation rooms, reception and waiting areas at the locations we visited. All were visibly clean and tidy. Staff maintained physical health equipment well and kept it clean.

Staff adhered to infection control principles, including handwashing. Staff were trained in infection prevention and control. The trust had relevant policies and procedures in place. Staff had access to personal protective equipment if required.

Health-based places of safety were kept clean and tidy. Cleaning records were up to date and demonstrated that areas were cleaned regularly and after use.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff followed good practice in medicines optimisation and did it in line with national guidance. There were systems in place to support the safe use of medicines across the crisis resolution and home treatment teams and the health-based places of safety. People’s medicines history was captured on admission to the crisis resolution service and regularly reviewed by the multidisciplinary team. Prescription changes were promptly shared with GPs, and relevant mental health teams.

Staff reviewed the effects of medicines on people’s physical health especially when someone was prescribed a high dose of antipsychotic medicines. The Northumberland and North Tyneside team had completed an audit between June and August 2025 and found that improvements had been made since the previous audit in Spring 2025. When checks were missed, staff recorded the reasons for omission. However, compliance with other physical observations on acceptance to the team was much lower. The audit had been shared for learning, and an action plan was in place.

An external review reported in December 2025 identified that potential risks from prescribed medicines were not always recorded. The trust continued to audit this to help drive improvement in capturing medicine-related risks and actions were recorded within people’s risk management plans. We saw examples where medicines risks and compliance were considered and discussed with people,and where appropriate, their carers. Where necessary, crisis resolution teams provided support with daily medicines administration. Staff also provided support for people commencing or re-instating clozapine. The trust planned to implement a new dedicated service to increase capacity for community-based clozapine commencement and monitoring.

Medicines record keeping varied between the teams. For example, scanned copies of paper prescriptions and related medicines records were sometimes difficult to find or missing. Some teams told us that they had always scanned paper prescriptions onto the electronic system, whilst one team told us they had only recently been advised to do this. Additionally, where teams delivered prescriptions or medicines to people at home, some teams recorded this on a paper chart whilst other teams made only electronic records.

Staff could access medicines for patients detained in the health-based places of safety when required from the adjacent mental health wards. Arrangements were in place to ensure people had access to critical medicines when in a health-based place of safety. However, we were unable to find the inpatient chart used to record medicines administration for 1 person in a health-based place of safety.

All crisis resolution teams had dedicated pharmacy support but roles and capacity varied between teams. Pharmacists attended review meetings at least weekly in all teams and were available for remote advice. Additionally, 3 teams held weekly prescribing review meetings supported by a specialist mental health pharmacist who offered a dedicated forum for medicines optimisation. Pharmacy staff told us they were available to speak with people who used the service and carers, and they could access the helpline. In 1 team, the pharmacist was also available to carry out home visits to discuss and review people’s medicines. Medicines information leaflets were provided in multiple languages and easy-read formats. People who used the service told us staff explained about their medicines.

Staff handling medicines completed the trust’s medicines management training. Average compliance in November 2025 was over 90%. An appropriate governance framework was in place to support non-medical prescribing. The trust’s medicines management audit had recently been extended to include the crisis resolution teams and health-based places of safety to provide assurance for the safe handling of medicines. The trust was also considering a digital platform to support oversight of medicines management practicalities, such as temperature monitoring and date checking.

The trust had shared care agreements with primary care providers for them to prescribe, monitor and review specialist medicines.