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

Well-led – 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.

Requires improvement: This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us they had opportunities to contribute ideas about the strategy of the service during team meetings and mutual help meetings. An away day had been booked in September for all qualified staff to discuss strategy.

The trust had a shared vision and strategy which were updated in in 2023. This was done in collaboration with service users, carers, staff, governors and other partners agencies. We viewed Board Papers which outlined the values and strategy. The values are; We are caring and compassionate, We are respectful, We are honest and transparent. The strategic ambitions are; Quality care, every day, A great place to work, Person-led care, when and where it is needed, Sustainable for the long term, innovating every day, Working with and for our communities.

At Mitford Unit, morale was low. Staff did not feel supported by ward managers and felt senior leaders were not always available or visible. Some staff told us they had seen members of the senior leadership team in person, however, this is not a regular occurrence. Staff told us that they had raised concerns to managers regarding safety but did not always feel these were heard and taken seriously. At Rose Lodge and Edenwood, staff told us managers within the service were open and transparent. Staff told us senior leaders visited the wards such as the CEO, chair and nurse director who were approachable and supportive. They said there was a culture of “It's ok to make mistakes but we need to learn from them.”

Regular management team and staff team meetings took place. Positive practice and staff achievements were shared in bulletins and by the Talk First team. Managers monitored morale via safety huddles, team meetings and through supervision/appraisals. Ward managers had access to dashboard systems so they could monitor key performance indicators (KPIs). Audits were conducted to ensure any areas for improvement were identified and addressed however, they did not always identify issues found during the inspection and where they were found, they were not always acted upon.

Staff told us they knew about the Freedom to Speak Up Guardian role and the processes for accessing this support if required. Staff also told us they knew how to access the trust's whistleblowing policy via the intranet. However, staff also told us they had spoken up about their worries but felt action was not always taken. Intervention from CQC and HSE was required before improvements were made in the safety and wellbeing of the staff team.

At Mitford Unit, staff told us they felt able to raise concerns, however, they didn't feel listened to by management or senior management. At Rose Lodge and Edenwood, staff and managers told us they felt able to raise concerns freely, without the fear of reprisals. We spoke to ward managers who were open and honest about things that had gone wrong and what had been learned since. There were also posters in the staff room to raise awareness. The trust had a Freedom to Speak Up Policy in place which was up to date. In relation to Mitford Unit, nine freedom to speak up reports were submitted in the last 12 months. 8 of those were concerns regarding culture and lack of staff support to staff. The latest raising concerns and whistleblowing reports were viewed. The guardian had attended team meetings on the ward to raise staff awareness.

The staff survey had very poor results in most categories. These included; We are compassionate and inclusive, We are recognised and rewarded, We each have a voice that counts, We are safe and healthy, We are always learning, We are a team, Staff engagement and Morale. The staff did not feel the skill mix was taken into account and felt at times staff were inexperienced and lacked knowledge of the people they were supporting. This led to staff not supporting situations appropriately putting both staff and people at risk of harm. Whilst staff raised these concerns, they did not feel listened to or that actions were taken to address their concerns.

There was an equality and diversity champion and a cultural ambassador in post to support staff. The trust had strategies in place to engage and involve staff including staff surveys. There were also staff networks and staff support groups available.

Staff were aware of trust policies and where information could be found. Staff told us that they understood the governance processes in place and the standard operating procedures in place for the service. However, were not always able to provide us with comprehensive information included some of their policies and procedures, particularly around safeguarding which increased risks to patients.

The effectiveness of the governance systems used on the wards was inconsistent. The trust failed to have sufficient oversight to protect service users from harm and abuse. The trust had awareness of the level of risks at the unit, evident due to the data and information available and shared with us however, actions taken by the trust had not been sufficient and undertaken with the required pace to assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity. We reviewed incidents of restraint where we saw that these had been approved by leaders but issues and concerns not raised. We also found that patient safety investigations had not been undertaken, despite service users being injured. Managers had access to dashboard systems which allowed them to monitor training, supervision, appraisal, audits and incidents. A number of clinical audits were carried out by managers, however, these did not always identify or address the concerns raised during the inspection. For example, care plans and positive behaviour support plans were completed but they lacked detail on what restraint should be used for each individual and how staff should do this safely. The trust failed to provide assurances about how staff were safely deployed and how they were assured that staff had the required competence and skill to effectively support patients in line with their behaviour plans. They did not provide sufficient detail about how they would deploy qualified staff to have oversight of any restrictive practice whilst it was being used and to ensure it was safe and ensure it was used as a last resort and for the shortest time possible.

People gave us mixed feedback on engagement and sharing information from family members. Some people told us they felt "very much involved" in their relative's care planning and discharge and felt the professionals involved worked well together to achieve the right outcomes. However, another family member expressed concerns about their relative being potentially moved away from their family and the impact they will have on them. Another family member told us that they don't have much say in making decisions and it "seems up to them [professionals]."

Staff and ward managers told us how they worked with external partners such as commissioners, local authorities and community providers to ensure continuity of safe care and treatment, facilitate discharge to appropriate settings, and share good practice/learning. However, staff expressed frustration with the delayed discharges on the ward and felt this impacted significantly on the wellbeing of the patients, and the staff team. They told us the issues with identifying appropriate packages and housing in the community were the main issue and felt there could be more joined up processes for addressing this.

A partner agency told us, "There is now a more inclusive partnership approach to working which smooths pathway and transition with real wrap around inclusive support."

The trust told us there were regular communication and collaborative working meetings with external agencies including the Integrated Care Board (ICB), NHS England (NHSE), third sector groups and advocacy. Clinicians from the trust’s autism services had contributed to regional development and national developments in autism. For example, NHS England’s Autism Programme work on adaptation of psychological therapies for autistic people. Clinical staff also contributed to the regional Autism Community of Practice and national Autism Practitioner Networks. There were regular meetings, in all three localities, with place-based commissioning teams to plan discharge, with representatives from health and social care in attendance. The meetings allowed any barriers to discharge to be discussed and provided regular oversight regarding progression to discharge. Despite this, issues with delays persisted. The trust’s clinicians regularly supported Care and Treatment Reviews (CTRs) via independent panels for individual patients. Each geographical locality had a police and partners meeting which provided a local forum for police, health and local authority representatives to review and understand data, demands and learn from incidents involving police and partners. During recent work to review the clinical model, the trust had requested an external quality assurance visit from colleagues in the Northeast and North Cumbria ICB and NHS England.

Staff reported incidents which included near misses, violence and aggression, self-harm, behaviours that challenge, property damage, patients going absent without leave and emotional abuse. Staff participated in debriefs following incidents. However, at Mitford Unit, staff said these did not always happen, or did not happen in a timely manner. Staff spoke positively about, and valued the involvement of the HOPE(S) practitioner and felt this has improved the quality of life for people, particularly those who were a delayed discharge.

There were collaborations to share good practice. For example, Rose Lodge introduced a daily Situation Report, chaired by the Clinical Manager and reviews the previous 24 hours on the ward. The meeting reviews the ward temperature, staffing levels, reportable incidents and estates and facility issues. The trust’s autism services have been involved in the development of new assessments and interventions for autistic people and the health conditions they may experience. This has included the development of the Autism Clinical Interview for Adults (ACIA) and trialling psychological therapies for anxiety and depression experienced by autistic people. There was also an ongoing review of NICE guidance for autistic people and people with learning disabilities, to ensure that the most up to date evidence-based interventions are provided. The trust has been involved in the development of innovative approaches to formulation, professional guidelines are followed for working with autistic people and MDT and handover process. This was successful in ensuring all relevant information was shared in the meeting and it followed a structure. It also supported ensuring handover was concise and shared the necessary risk and other pertinent critical information. The HOPE(S) team have been involved in supporting staff to reduce long term seclusion. However, we had concerns that the trust were not always following best practice in relation to the the use of restraint and restrictive practice. Therefore, we were not assured that the review and action planning from debrief and incident reviews were robust enough to inform learning and improvement.