- SERVICE PROVIDER
East Lancashire Hospitals NHS Trust
This is an organisation that runs the health and social care services we inspect
Report from 13 August 2025 assessment
Contents
Ratings - Community health inpatient services
Our view of the service
The intermediate inpatient and stroke rehabilitation services at East Lancashire Hospitals NHS Trust are based across 4 sites: Albion Mill, Burnley General Hospital, Clitheroe Community Hospital and Pendle Community Hospital.
Albion Mill is a supported living service in Blackburn where care is provided in partnership with Blackburn with Darwen Metropolitan Borough Council, which includes an intermediate care ward. At the time we inspected, the ward had 13 beds which were open to admissions due to refurbishment works impacting part of the building.
Burnley General Hospital has three community inpatient wards: Ward 19 which has 25 beds, Ward 22 which has 27 beds and the Rakehead Rehabilitation Centre which is a neurological rehabilitation ward with 17 beds within a purpose-built centre on the hospital grounds.
Clitheroe Community Hospital has one 32-bedded ward, Ribblesdale ward.
Pendle Community Hospital consists of three 24-bedded wards: Marsden ward, which is a specialist stroke rehabilitation ward, as well as Hartley and Reedyford wards which are both general rehabilitation wards. Reedyford ward was closed at the time we inspected.
The intermediate care wards and community services sit within the Community and Intermediate Care division of the trust, with the exception of Marsden Ward which sits within the Medicine and Emergency Care division.
We carried out an unannounced inspection of all 4 community inpatient sites on 4-6 March 2025. Our inspection was triggered due to concerning information we received about Pendle Community Hospital in December 2024.
During our inspection, we spoke with 30 members of staff including doctors, physiotherapists, occupational therapists, pharmacists, registered nurses, healthcare assistants, housekeepers, ward managers and senior managers. We also spoke with 21 patients and 20 relatives about their experience of the service. We carried out 5 structured observations of care and we observed a handover and a multi-disciplinary team meeting. We reviewed 19 sets of patients’ records, 24 prescription charts and a range of other documents including ward management records, policies and procedures. We looked at 33 quality statements.
We rated the service as Requires Improvement overall, with Requires Improvement ratings for the Safe and Responsive key questions and Good ratings for Effective, Caring and Well Led.
We found 3 breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 in relation to person-centred care and involvement of patients (Regulation 9), patient safety including the management of medicines (Regulation 12) and staffing (Regulation 18).
We did not see sufficient evidence that staff involved patients and those close to them in the planning and delivery of care. At times, staffing pressures were impacting negatively on the quality of patient care, as staff did not always have the capacity to promptly meet people’s needs. Medicines were not always managed safely. People’s care records were not always stored securely which presented a risk to people’s confidentiality. However, the care environment was clean and overall well-maintained. Staff were providing compassionate care to people. People were receiving effective care which usually met their individual rehabilitation needs.
Action we have taken
We have asked the provider for an action plan in response to the concerns found at this assessment.
People's experience of this service
We spoke with 21 patients and 20 family carers during this assessment. The patients we spoke with were happy with their care overall. Patients and relatives told us that staff were compassionate and treated them well, although some patients said that staff did not always have the capacity to respond to them quickly when they needed support. Some carers also said staff could be abrupt with them at times which they felt was due to being overstretched because of staffing pressures. Patients usually told us that the food was good and that they were able to access dietary options which met their individual needs. However, some of the relatives of patients at the Rakehead Centre said the food there was not good. Some patients and relatives told us that they received all the information they wanted from staff. However, some said they would have liked more information, patients did not usually have a copy of their care plans and patients and relatives told us that they had not been involved in the care planning process. Patients and families were usually happy with the level of rehabilitation support they were receiving on the wards.
While the people we spoke with expressed they were happy with their care, our assessment found that some elements of the care did not meet the expected standards, particularly in relation to the recording of patient and family carer involvement in care planning and delivery.
Mental Capacity Act Compliance
- 100% of staff working in the community inpatient service had received training in the Mental Capacity Act as part of the trust’s level 1 safeguarding module. Over 90% of eligible staff had received more in-depth training as part of the levels 2 and 3 safeguarding modules on all wards.
- The staff we spoke with had a good understanding of the Mental Capacity Act, to the extent that this was relevant to their role and understood the core principles of the Act, for example the requirement to assume capacity in the first instance.
- Staff made Deprivation of Liberty Safeguards applications when required and monitored the progress of applications to supervisory bodies.
- There were 317 Deprivation of Liberty Safeguards applications made in the last 12 months across all the community inpatient wards to protect people without capacity to make decisions about their own care.
- These were highest in Hartley ward at Pendle Community Hospital, Ribblesdale ward at Clitheroe Community Hospital and ward 19 at Burnley General Teaching Hospital.
- The provider 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 provider regarding the Mental Capacity Act, including Deprivation of Liberty Safeguards.
- Staff took all practical steps to enable patients to make their own decisions.
- For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis regarding significant decisions.
- Where patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.
- The service had arrangements in place to monitor adherence to the Mental Capacity Act. Staff audited the application of the Mental Capacity Act and acted on any learning that resulted from it.