Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last inspection we rated well-led as good. At this inspection, the rating has remained good. Leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued. Overall governance processes operated effectively although internal audits had highlighted that further improvement was required in some areas, specifically in relation to record keeping within the health-based places of safety. Staff were aware of risks and managed them well. Teams had access to the information they needed to provide safe and effective care. Staff collected and analysed data about outcomes and performance and used this to identify improvement.

Good: This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. The trust vision, values and strategy were incorporated in the trust corporate induction. The trust provided culture awareness training.

In 2023 the trust launched their strategy ‘With You In Mind’ which set out 5 strategic ambitions to deliver safe, high quality care in line with the Government’s 10 year health plan for England. One of the 5 sub-groups incorporated urgent and crisis care with workstreams that measured outcomes and was overseen by the model of care and support programme board. Staff were involved in implementing and monitoring workstreams which included crisis and liaison response times, metrics regarding the care of frequent attenders and intensive case management outcomes.

Managers could explain how they were working to deliver care within the budgets available. Staff gave several examples of ways in which quality was implemented across the service and when innovative ways of working had succeeded without scrutiny regarding costs. However, managers were aware that care had to be delivered within their given budget and were mindful of the current economic climate.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had the skills, knowledge and experience to perform their roles. Leaders had a good understanding of the services they managed and could explain clearly how the teams were working to provide high quality care. There was a range of senior support within teams such as team managers, clinical leads, nurse consultants, clinical nurse specialists, matrons and consultant psychiatrists. Staff told us leaders were visible and they knew how to contact senior managers when required.

Prior to our inspection, some staff in the North Cumbria team had raised concerns with the trust and with CQC about leadership and culture which had been addressed in the Freedom to Speak up process.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff and leaders actively promoted staff empowerment to drive improvement. They encouraged staff to raise concerns and promoted the value of doing so. Staff were confident that their voices would be heard. The trust had a Raising Concerns policy to support staff to speak up and we saw information displayed that promoted the service across the team sites we visited. Staff we spoke with said they would raise concerns and felt comfortable doing so. They had easy access to the Freedom to Speak Up champions.

A Freedom to Speak Up Guardian worked alongside the trust’s senior leadership team to ensure staff had the capability to speak up effectively and were supported appropriately if they had concerns regarding patient care. Staff said leaders acted with openness, honesty and transparency.

There was a culture of speaking up where staff actively raised concerns and those who did, including external whistleblowers were supported, without fear of detriment. When concerns were raised, leaders investigated sensitively and confidentially, and lessons were shared and acted on. We reviewed Freedom to Speak Up information for the service between 1 December 2024 to 30 November 2025. There had been 9 cases; 2 related to the Northumberland and North Tyneside team, 5 for North Cumbria, 1 for the health-based place of safety at St Nicholas Hospital and a generic one about administration. At the time of our inspection, 3 remained open and were still being investigated. One of the North Cumbria cases had been sent to CQC prior to the inspection which related to leadership, staffing levels and caseload size, culture and staff morale, and medical cover and equity over the East and West areas, all of which were deemed to put the health and safety of staff and people who used the service at risk. The trust had put actions in place to address the areas of concern and had requested feedback from staff about how to make the workplace a positive space. Staff had attended the trust culture awareness training with a view to discuss next steps at future meetings to further make improvements. However, some staff told us they still had concerns about staffing and the consultation about flexible working. Similar themes had been raised to senior managers, specifically about culture, leadership, patient care and safety, and staff wellbeing from the Northumberland and North Tyneside team.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

The trust undertook equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the people it supported. The trust produced an annual Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) report. We reviewed the 2025 report which gave a snapshot of the trust as of 31 March 2025 and also reviewed findings from the NHS staff survey which took place in Autumn 2024. WRES and WDES data are only available at trust-wide level.

The WRES findings showed representation of Black, Asian and Minority Ethnic (BAME) staff across the trust had increased by 2%, which equated to 13% of its total workforce, from 2024 to 2025. All bandings had shown an increase of BAME staff. However, from the same time period, data showed that white applicants were 2 times more likely to be appointed than BAME staff following shortlisting. The gap had doubled of BAME staff who had experienced bullying, harassment or abuse from patients, relatives or the public compared to white staff at 26% and 48% respectively.

The WDES findings showed representation of disabled staff across the trust had increased by nearly 1% although had dropped by 4% and 3% for non-clinical band 5 or below staff and clinical band 5 or below staff respectively, and 13% for medical consultants. Non-disabled staff were 1.4 times more likely to be appointed following shortlisting. The number of non-disabled and disabled staff who had experienced bullying, harassment or abuse from patients, relatives or the public had increased although the gap between them had decreased by 2%.

The trust had produced a 10-point plan to address some of the disparities and to continue the work towards being an anti-racist and anti-ableist organisation.

There were equality and diversity champions within the service and staff knew how to contact someone when required. The trust had a range of equality and diversity networks which staff could attend for support, advice and advocacy such as the cultural diversity network, disabled staff network, LGBT+ staff network, and an armed forces and veterans network. In addition, there were informal support groups such as the wellbeing community, menopause café and staff carer network.

Managers put reasonable adjustments in place for staff members to help them carry out their role. Staff gave us examples of adjustments that had helped them to do their job more easily. Staff were able to apply to work flexibly and had flexible working agreements to account for personal circumstances such as caring responsibilities or health issues. Managers told us each request was reviewed individually and they were supported by trust policies and procedures and staff within human resources to make fair and just decisions.

Prior to our inspection, managers in the Cumbria teams had recently undertaken a staffing consultation to review people who had flexible working arrangements in place with an aim to reduce their reliance on the use of agency staff. Some staff were unhappy with the consultation although managers told us they wanted to ensure the process was fair for all and staff had the opportunities to discuss any concerns they had individually with them. Managers from the service had proceeded with the consultation to ensure that the needs of the service were being met whilst also supporting staff who still required flexible working. The consultation was ongoing whilst we inspected the service and results had not been finalised.

Systems and processes had identified areas where improvements were required in relation to record keeping, training and access to the services and action plans were in place. However, the service had clear responsibilities, roles and systems of accountability to continually make improvements. They acted on information about risk, performance and outcomes, and shared this securely with others when appropriate.

We found areas of concern related to timely assessments for very urgent referrals and training concerns across the crisis resolution and home treatment service. We found that managers had highlighted concerns and action plans were in place to make improvements. There was a clear framework of what must be discussed at team level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. Managers and leaders attended operational governance meetings based upon quality, performance, business delivery and learning. Information would feed into a weekly safety meeting.

Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level. Action plans were monitored at governance meetings and staff gave us examples of changes that had been made following feedback or learning. Mortality review actions and learning was shared in trust wide safety groups and quality and performance meetings.

Staff undertook or participated in local clinical audits. We reviewed various audits related to the efficiency and quality of the service and found that staff had highlighted where they had concerns. Action plans or mitigations were in place to make improvements in relation to record keeping in the health-based places of safety, culture and leadership and safe staffing. Consultations were ongoing regarding staff concerns about the health-based places of safety.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of people who used services.

Managers had access to real time ‘at a glance’ dashboards so they could monitor and review the teams’ performance and manage risk and issues quickly. Information included referrals, potential breaches, caseloads, frequency of visits and risks for staff when visiting people at home, such as 2 person visits.

Managers and leaders attended a range of clinical governance meetings. We reviewed meeting minutes from January to November 2025. Topics discussed included lessons learnt, team updates and wellbeing, and audit feedback. Actions were included where required.

Managers and senior leaders were aware of the challenges the teams encountered to ensure they provided a safe and effective crisis resolution and home treatment service whilst also being expected to manage and coordinate care of those detained in the health-based places of safety. The main challenges consisted of the environments not always being fit for purpose, staff not being PMVA trained and the risk to staff being injured or causing them distress or anxiety.

Managers and senior leaders maintained and had access to the risk register at directorate level. Staff could escalate concerns when required. Staff concerns matched those on the risk register and the issues we found on inspection. The concerns about the health-based places of safety were recorded on the risk register. The register included the mitigations in place to reduce the risk, and any gaps in controls of those risks. These risks were rated as moderate once mitigations were in place. Other risks included staffing shortages in the North Cumbria team, which was rated as high risk even with mitigations in place.

The service had business continuity plans in place for emergencies to ensure they could continue to run the service for example in adverse weather, environmental issues or a flu outbreak.

Where cost improvements were taking place, they had not compromised care. However, managers said there was a higher demand for crisis and community services and organisational pressures had led to increased scrutiny.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, worked well and helped to improve the quality of care. Staff had access to laptops so they could record their notes contemporaneously and attend meetings remotely.

Information governance systems included confidentiality of care records. Staff received and were up to date with information governance and data security awareness training.

Team managers had access to information to support them with their management role. This included information on the performance of the service such as electronic dashboards, staffing rotas, electronic care records and incident reporting systems. Information was in an accessible format, and was timely, accurate and identified areas for improvement.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Directorate leaders engaged with external stakeholders. The service was part of the North East and North Cumbria integrated care system. This included local authorities, the integrated care board (ICB), primary care, and other organisations. The trust worked closely with the ICB who were responsible for planning, organising and funding health services. Examples included further development of services for people who required more intensive and assertive community mental health support, following national reviews of serious mental health tragedies. We received feedback from the Integrated Care Board who had concerns the service did not always function effectively or consistently, specifically in relation to communication, referrals being rejected when people required support and some prescribing disparities. However, they also reflected that the trust acknowledged where improvements could be made and were responsive, keen and open to working with external partners.

External partners praised the North Cumbria team in relation to their contribution to the local mental health transformation regarding the national pilot to bring services into the community and help mitigate inequalities in health care provision.

The trust liaised closely with partners such as the local police and produced joint guidance with regard to Right Care, Right Person to ensure they worked effectively together for tasks. This included mental health assessments in the community, incidents requiring police attendance, did not attend processes, use of trust staff as appropriate adults, concern for the safety of a person or staff member and escalation processes and information sharing. Information was collated and monitored through trust governance processes. Managers attended the monthly multiagency police and partners meeting and discussed items relevant to the teams such as section 136 detentions.

The trust had service level agreements with other providers such as the local acute trusts regarding the administration of the Mental Health Act 1983, and for the provision of the NHS 111 option 2 service.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Staff were given the time and support to consider opportunities for improvements and innovation and this led to changes. Managers and staff told us about current quality improvement initiatives taking place across the service which included embedding a consistent model across the service. Examples included a project to improve the pathway and interface between crisis resolution and home treatment teams and community mental health teams to provide safe, person-centred transitions between services.

The Cumbria team participated in the ‘Hope Haven’ national pilot in conjunction with partners to provide a 24/7 neighbourhood service that eliminated referral and discharge processes and provided a range of services to meet people’s individual needs.

Teams participated in accreditation schemes relevant to the service and learned from them. The Newcastle and Gateshead and Northumberland and North Tyneside teams had been accredited under the Quality Network for Crisis and Home Treatment teams. The Sunderland and South Tyneside team was undergoing the re-accreditation process. The North Cumbria team planned to seek accreditation in the future.