East Lancashire Hospitals NHS Trust

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• 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 assessment we rated this key question requires improvement. At this assessment the rating has remained 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.

The service was in breach of regulation for people’s safe care and treatment, the management of medicines and safe staffing (Regulations 12 and 18).

This service scored 59 (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. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learned to continually identify and embed good practice.

The trust had a detailed incident reporting policy which was approved by the Patient Safety Group in March 2023. The staff and managers we spoke with were familiar with the incident reporting policy and system, and could give appropriate examples of when they would report something as a patient safety incident, such as patient falls or development of pressure ulcers.

Rates of serious incidents requiring a patient safety incident investigation (PSII) were low (2 across all wards in the 12 months preceding our inspection). Less serious incidents were reported regularly on all wards and incident data showed a proactive reporting culture with issues like staffing shortages being reported as safety incidents. There was an overarching action plan being implemented to reduce the rate of pressure ulcers on the wards due to this category of incidents having been identified as one of the most frequently reported across the trust. No never events were reported on any of the community inpatient wards in the 12 months preceding our inspection.

Staff understood the duty of candour. There was a written policy on openness and honesty when things go wrong and also a duty of candour flow chart for staff to follow as an appendix to the incident reporting policy. Staff were open and transparent, and gave patients and families a full explanation if and when things went wrong. Data was gathered to enable the trust to monitor compliance with the duty of candour and rates of incidents requiring a duty of candour report were low, ranging from 1 on Marsden ward to 12 on Ribblesdale ward in the 6 months preceding our inspection.

Staff told us that they received feedback about lessons learned from incidents, both internal and external to the service, for example at team meetings and in email bulletins and patient safety alerts, and we saw evidence of this in the team meeting minutes we reviewed and example alerts from the 12 months preceding the inspection. We saw examples of improvements to the service due to lessons learned from incidents, including improved systems for the identification and provision of appropriate care to patients with a learning disability and/or autism and improvements to information sharing systems to ensure all staff, including therapies staff, took appropriate action to reduce patients’ risk of developing pressure ulcers.

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

The service’s referral and admission processes ensured that essential information about the patient was received to determine if the patient’s needs could safely be met. Where patients were transferred to the community inpatient wards from acute medical wards elsewhere within the trust, which was the case for almost all patients, staff had immediate access to their care records via the trust-wide electronic record keeping system. Staff and managers told us that they had access to all the information they needed in order to meet patients' care needs from the point of admission. Patients told us that they had felt well supported during their admission to the wards.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. All patients were reviewed by their multi-disciplinary team, including doctors, nurses, therapists and, in some cases, a Complex Case Manager and this included ongoing planning for discharge. The patients and family carers we spoke with were usually aware of the plans for discharge, for example whether the patient would be going home or into a supported living placement and what support was being arranged for them in the community. However, people did not always have written discharge care plans on their records.

The service worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving patients' 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.

The trust had written policies on safeguarding children and adults at risk of abuse, which were approved by the Safeguarding Committee in 2024. All staff received training specific to their role on how to recognise and report abuse. Staff undertook training in safeguarding adults at levels 1, 2 and 3 and in safeguarding children at levels 1 and 2. All staff teams were over 85% compliant with all modules, with the sole exception of level 3 training at Albion Mill (63% compliant). Managers told us that training compliance at Albion Mill may not be reflective of the actual numbers of staff up to date with training, due to the recent transfer of a cohort of staff from Blackburn with Darwen Borough Council at this service. All the staff we asked about safeguarding training told us they were up to date with this and staff at all levels knew how to report a safeguarding concern on their ward. The written policies included a flow chart which staff could refer to for guidance on the reporting process.

Ward managers described good working relationships with local safeguarding teams, with systems in place to ensure concerns were reported promptly. The trust monitored rates of safeguarding referrals from the wards and we did not identify any concerning themes or trends from the safeguarding incidents we reviewed (the most recent 5 referrals from each ward). Ward managers also explained how patients, including those with protected characteristics under the Equality Act, were protected from harassment and discrimination. Staff received training on equality, diversity and human rights as part of their mandatory training modules and compliance for all wards was at least 95%. The patients we spoke with told us they felt safe on the ward and said they had not experienced any inappropriate treatment from staff, with the sole exception of one patient who raised concerns about the way some of the night staff had spoken to her. We raised this with the ward manager at the time and appropriate action was taken. The family carers we spoke with all told us that they believed their relative was safe and well cared for on the ward.

Where patients lacked capacity to consent to being on the ward, a Deprivation of Liberty Safeguards (DoLS) authorisation had been applied for promptly and was in place at the time we inspected, and the trust had systems for monitoring this internally to ensure compliance with the Mental Capacity Act. In the 12 months prior to our inspection the trust had seen an improving picture in relation to the number of DoLS authorisations applied for as a result of audit findings and an improvement action plan (from 135 trust-wide applications in April 2024 to 254 in February 2025).

Systems were in place to identify the risks relating to each patient’s care and care was planned to mitigate risks as far as possible. However, we did not see adequate evidence that the service worked with patients to understand and manage risks by thinking holistically so that care met their needs in a way that was safe and supportive and enabled them to do the things that mattered to them.

All the care records we reviewed included a range of standard risk assessments relevant to the service including risk of falls, tissue viability (risk of developing a pressure ulcer) and risk of malnutrition. Risk assessments were completed using nationally recognised tools, such as the Waterlow risk assessment for tissue viability and the Malnutrition Universal Screening Tool (MUST) for malnutrition risks. Some patients had additional risk assessments, for example relating to the use of bed rails. Risk assessments were reviewed and updated regularly, including following relevant incidents such as falls. Key areas of risk were highlighted on a front page of each patient’s electronic records to ensure staff were made aware of these at the earliest opportunity.

However, we did not see evidence on the care records of how patients and their families had been involved in assessing risk and developing care plans to manage each identified risk. Patients and their relatives usually told us that they felt as involved as they wished to be in their care on the wards, however some patients told us that they had not been given as much information about their care as they would have liked. People generally said they did not have a copy of their care plan and family carers said they had not been involved in planning their relative’s care.Multidisciplinary team meetings and care handover meetings did not generally involve patients. Although the care handover we observed on Hartley ward took place at people’s bedsides, these were a discussion between staff members about the patient, with minimal collaboration and involvement of the patient themselves in the conversation. Following the inspection, the trust told us that additional training had been provided to staff to prompt them to include narrative comments about patients’ and carers’ individual views in the relevant sections of the care plans.

Staff used a nationally recognised tool to identify deteriorating patients (the National Early Warning Score (NEWS) 2 scoring system) and escalated concerns appropriately. All patients had their vital signs measured and their NEWS2 score calculated at least every 12 hours and there was an escalation system for patients to be checked more frequently if there were any indicators that this was necessary. We observed appropriate action being taken promptly on Hartley ward to respond to a patient whose blood oxygen levels were deteriorating following calculation of their NEWS2 score.

Staff knew about and dealt with any specific risk issues. It was clearly highlighted in care records and handover information where patients had any additional specific risks, for example a pressure ulcer which required care to prevent deterioration. All patients received a venous thromboembolism (VTE) risk assessment on admission and preventative measures were taken to prevent patients developing a VTE due to their reduced mobility while on the wards. Information was displayed on the wards to highlight particular areas of risk to staff and relatives, for example sepsis, pressure ulcers and falls.

Staff told us that they had 24-hour access to mental health support and the two specialist neurological rehabilitation wards (Marsden ward at Pendle Community Hospital and the Rakehead Rehabilitation Centre at Burnley General Teaching Hospital) had an assistant psychologist as part of the multi-disciplinary ward team. All patients had a brief assessment of their emotional and mental wellbeing at the point of admission to identify any risks of this nature. On wards 19 and 22, the trust was piloting a wellness questionnaire for patients to improve their systems for identifying patients’ mental and emotional health related needs as well as timely recognition of any deterioration in patients' physical health.

Staff shared key information to keep patients safe when handing over their care to others. Shift change handovers included all necessary key information to keep patients safe. A template document was shared with the incoming staff team, which included a summary of each patient’s risks and needs and the nurse in charge of the outgoing shift also provided a verbal handover at each patient’s bedside. However, this only minimally involved the patients during the handover we observed and we also identified some dignity and confidentiality concerns as the verbal handover was conducted in the presence of other patients on the shared bays.

The service usually detected and controlled potential risks in the care environment and made sure that the equipment, facilities and technology supported the delivery of safe care. However, we found some examples during the inspection where the management of the care environment and/or equipment could have been improved.

Regular risk assessments were carried out in relation to the care environment including fire risk assessments and infection prevention and control risk assessments, and action was taken and recorded in relation to any identified risks. The ward layout on all wards enabled staff to observe the patients in shared bays and/or side rooms and a ‘bay tagging’ system was used to cohort patients who needed additional observation together. Patients could reach their call bells, and the environment did not hamper staff from promptly responding to patients who needed assistance.

There was a clear policy for staff to follow in the event of a medical emergency. All wards had accessible resuscitation equipment and emergency drugs that staff checked regularly. The records of the checks on all the resuscitation trollies we reviewed were complete and up to date. There was one airway management stock item missing from the resuscitation trolley on ward 22 when we checked it and this had not been identified by the ward’s own checks. Staff took immediate action to address this when we informed the nurse in charge of the ward. Also, on ward 22, the checklist did not accurately reflect what was stored in each drawer of the resuscitation trolley.

The service had enough suitable equipment to help them to safely care for patients including hoists, stand aids, wheelchairs and physiotherapy equipment. Records were available to demonstrate that all equipment requiring servicing and/or calibration was maintained appropriately. We also saw records which confirmed that Portable Appliance Testing (PAT) was up to date for the electrical equipment used on the wards.

The clinic rooms and sluices were orderly and had adequate medical equipment and stocks of single use items. In 2 sluices we found urinalysis test strips which had passed their expiry date and we informed the ward staff of this who immediately removed them. Following the inspection the trust told us that urinalysis and ketone test strips had been added to the weekly checklist to prevent a recurrence of this and that the risk would have been mitigated in any event as staff routinely check the date on all strips before use. Clinical waste including sharps was usually managed appropriately and stored safely in staff only areas, although we found 1 sharps bin which was in use but which had not been marked with the date of opening, which was not best practice. The trust audited their waste management systems and processes and took action to improve where any non-compliance was identified.

The care environment on all the wards was pleasant overall, with wards mostly appearing well maintained and always clean and free from unpleasant smells. The feedback from patients and family carers was that the care environment was pleasant, comfortable and supported their recovery. Patients with impaired mobility told us that they were able to access all areas of the ward they needed to use, with support from staff if needed. Relatives told us that there were areas at each location where they could go with their family member if the patient was able to leave their bed, including day rooms, cafés and outside areas.

We noted some minor environmental maintenance issues, including black mould in the sink sealant and unfilled holes in the wall in one bathroom on Hartley ward, marked paintwork on Hartley and Marsden wards, plaster damage on the walls where things had been taken down on ward 19, and chipped paintwork on the doorframes on ward 22. There was a lack of storage space for equipment on Marsden ward, leading to wheelchairs being stored in the day room and hoists being out in the corridors. Staff had done everything they could to mitigate the risk to patients and visitors from this and the risk was included on the trust’s risk register to ensure oversight and ongoing mitigation of the issue.

The trust had a range of systems to monitor the care environment including Patient Led Assessments of the Care Environment (PLACE), monthly and yearly Matron’s checks and a health and safety audit at Albion Mill (as the PLACE assessments did not cover this location). Reports from the most recent assessments showed a high level of compliance with expected standards and evidence that action was taken in response to any issues which were identified.

The service did not always make sure there were enough qualified, skilled and experienced people, who received effective support, supervision and development and worked together effectively to provide safe care that met patients’ individual needs.

The trust had a pre-employment checks policy which required information to be obtained for all members of staff in compliance with the Regulations, including references, proof of professional registration with the relevant body such as the Nursing and Midwifery Council and an enhanced DBS check, which was last reviewed and approved by the trust’s Joint Negotiating Consultative Committee in February 2025.

The trust produced a monthly safer staffing report which showed that, during the month prior to our inspection, no shifts were below 80% of establishment for registered nurses or support workers across all the community inpatient wards. Individual incidents of staffing below establishment were also captured by this report and there were a total of 8 across all 6 wards in the specified period (Marsden ward was not included in this report due to sitting within another trust directorate). Staffing boards displayed on each ward showed that the actual number of staff on shift matched the planned establishment levels for each ward for support workers and registered nurses.

Vacancy rates for the community inpatient service were low - 3% of whole time equivalent (WTE) staff for qualified nurses, 2% WTE for Band 3 support workers and 4% WTE for Band 2 support workers. Turnover rates were variable, ranging from 2% on Marsden ward to 17% on Hartley ward, as at February 2025. Sickness rates were higher across all wards, ranging from 8% on Ribblesdale ward to 16% at the Rakehead Centre in January 2025. The ward managers could adjust staffing levels according to the needs of patients - morning staffing calls were attended by the managers and Matrons for all community inpatient wards and staffing across the service was adjusted as needed by the acuity of each ward.

Despite the staffing levels falling consistently within the trust’s tolerance thresholds for safe staffing at the time we inspected, we heard from staff, patients and relatives on all wards that staffing pressures were at times impacting on staff’s ability to provide a good standard of care to people. We also saw a staffing analysis the trust had carried out covering the period 1 October 2024 to 21 March 2025, which compared actual staffing levels to the needs of the ward taking patient acuity into account, which showed Hartley, Marsden and Ribblesdale ward and wards 19 and 22 consistently falling below the required levels over this period. The Rakehead Centre’s staffing improved over the period, with actual levels falling below the required levels for patient need at the start of the period but improving over time. Staffing levels at Albion Mill were shown in this report to be consistently over the level required to meet the needs of patients during this period of time.

We heard from 8 staff members that the establishment levels for their ward were insufficient to meet the needs of patients and/or that the ward was frequently short-staffed. Also, 6 patients (on different wards) told us their ward was short-staffed at times, especially at night and over the weekend, and/or they had to wait a long time for their buzzers to be responded to, and we observed this happening at times of high acuity (for example during our evening visit to Hartley ward). Some patients told us they sometimes had to wait when they needed support to go to the toilet and a member of staff also acknowledged that this could happen when the ward was very busy.

Due to the system of bay-tagging, some staff were meant to stay on the bays at all times, but then there wouldn’t always be another staff member available to support patients who needed to leave the bay, for example to use the toilet. Staff also told us that sometimes they were expected to ‘bay-tag’ and simultaneously undertake 1:1 observations for an individual patient in that bay. Some of the family carers we spoke with told us that there were not always enough staff to meet patients’ needs. We were told on Hartley ward that, due to the housekeeper being on long term leave and no cover being arranged, care staff had to support with meals which placed additional pressure on them and impacted their ability to attend promptly to people’s personal care. Following the inspection, the trust told us that a total of 16 shifts out of 59 had no housekeeper cover during January and February 2025 and that the shortfalls were promptly escalated, and additional cover was requested in accordance with trust policy.

Agency staff use was very low across all wards. Bank staff use varied in the month preceding our inspection from 7% on Marsden ward to 20% on Hartley ward and at Albion Mill. Ward managers told us that bank staff use could increase when the needs of a particular cohort of patients were more acute, but they offered bank shifts to substantive staff members first to try to maintain as much consistency as possible for patients. The trust had systems in place to regularly review staffing levels and bank and agency use on all the wards. Each ward had sufficient medical and allied health professional (physiotherapy and occupational therapy) staff to meet the needs of patients. On call medical support was available out of hours to all the wards.

All staff, including bank and agency staff, received a full induction before they started work on the ward. The trust had a written induction policy which set out the requirements for staff induction, the current version of which was approved by the trust’s Joint Negotiating and Consultative Committee in February 2024. The staff we spoke with, including bank and agency staff, all told us that they had received a ward-based induction when they commenced work on the ward.

Staff had received and were up to date with appropriate mandatory training including safeguarding, moving and handling and life support at a level appropriate to their role, infection prevention and control, health and safety, fire safety, information governance and equality, diversity and human rights. On most wards compliance rates for all modules were over 90%, the only exceptions to this were information governance training on ward 19 (85%) and level 3 safeguarding training on ward 19 (86%) and at Albion Mill (63%). Ward based staff also completed mandatory ‘essential to role’ training which included dementia awareness, learning disabilities and autism, medicines management and pressure ulcer prevention. Compliance rates for these modules for eligible staff were all 80% or over except for freedom to speak up level 2 at Albion Mill (77%) and FFP3 mask fitting on ward 19 (70%) and at the Rakehead Centre (79%). The ward managers we spoke with described how they monitored mandatory training and alerted staff when they needed to update their training.

Staff received annual performance reviews following a standard format which included a review of the employee’s capability and performance in their role, their demonstration of the trust’s values and their training needs and development aspirations. At the time we inspected, 80% or more of staff on each ward had received an appraisal in the preceding 12 months. However, ward managers told us that there was no system for nursing and support staff to have regular 1:1 supervision between their annual performance reviews, this was offered on a more ad hoc basis as needed by individuals. This placed the onus on individuals to request supervision and it was unclear how managers were ensuring all staff were regularly supported to ensure competence in their roles was maintained. We saw evidence that, at the time of our inspection, the trust was considering a proposal for the re-introduction of regular clinical supervision sessions for nursing and support staff, as these had been taking place prior to the COVID-19 pandemic and had to be stood down due to the increased pressures on the wards at this time. There was already a rota in place for therapies staff across the community inpatient service to receive regular clinical supervision.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The trust had a written infection prevention and control policy which was approved by the trust’s Infection Prevention Committee in 2022 and was due for review in September 2025. This set out the trust’s overarching strategy and key areas of responsibility in the identification, prevention and control of infection and was supported by a range of policies and procedures on specific areas such as hand hygiene, environmental cleaning, dress code and the use of personal protective equipment (PPE). Staff received training on infection prevention and control as part of their mandatory training and, at the time we inspected, over 90% of staff across all the community inpatient wards were up to date with this training.

All the wards we visited were clean at the time of inspection and we observed cleaning taking place. Cleaning equipment and products were stored safely in staff only areas. We reviewed cleaning records on all wards and the majority of these were complete and up to date (although we found some gaps in the records for Albion Mill and ward 19).

Patient led assessments of the care environment (PLACE) were taking place on all wards and the reports from recent PLACE assessments showed high scores for cleanliness and hygiene (85% or above for all wards). The patients and relatives we spoke with all told us that the wards were kept very clean and no one raised any concerns about the cleanliness of the environment. Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned – we saw clean stickers in place on the stored equipment we inspected.

Staff followed infection control principles including the use of personal protective equipment (PPE). We observed staff complying with hand hygiene best practice and washing their hands when moving between patients. There were well stocked PPE dispensers and hand sanitiser dispensers situated throughout all the wards. The wall mounted sanitiser dispensers at Burnley General Teaching Hospital were empty due to a stock replenishment issue, but staff had mitigated this by using free standing dispensers.

Where patients had been diagnosed with an infection, there were barrier nursing systems in place to prevent transmission between patients and we observed staff complying with these. Reverse barrier nursing was also in place for immunocompromised patients, for example people currently receiving chemotherapy. Staff were also compliant with the trust’s guidance to be ‘bare below the elbows’ in clinical areas. Rates of staff vaccination against Hepatitis B were over 80% across all wards except Albion Mill (where it was not possible to accurately establish the rate due to staff transferring from another care provider). However, staff rates of flu and COVID-19 vaccination were low across all wards (between 0% and 20%).

The trust monitored incidence of hospital acquired infections such as C. difficile and audited records to continually monitor compliance with national best practice in infection prevention and control and antibiotic use. If 2 or more incidences of the same infection occurred on a ward this was managed through an infectious disease outbreak procedure to ensure the risk of further transmission was reduced as far as possible. There were only 2 outbreaks across all wards in the 12 months prior to our inspection and both these cases related to 2 incidences of C. difficile infection only.

The trust also carried out regular infection prevention and control audits on each ward and the reports of the most recent audit on each ward at the time of our inspection showed high levels of compliance with the trust’s policies relating to cleanliness and infection prevention and control best practice. Also, the monthly Matron’s reviews of the wards included a range of checks relevant to cleanliness and infection prevention and control and the reports of these from each ward showed compliance with expected standards overall and, where issues had been identified, evidence of action being taken to address the issue in a timely manner.

The service had systems and processes in place for the appropriate and safe handling of medicines. Pharmacy support to the wards varied and in some areas was largely remote which posed a risk of delays in supplying medicine on discharge. However, this risk and also a more general safety risk relating to pharmacy staffing levels had been identified by the trust. Following the inspection the trust told us that in the 12 months preceding our inspection there were only 2 instances of delayed discharge relating to issues with medication.

The trust had systems and processes in place for the appropriate and safe handling of medicines. There was good compliance with the trust’s medicines related training including medicines management, medical gases and insulin (over 90% at the time we inspected). Patients were ‘referred to pharmacy’ for any support they may need with their medicines on discharge from hospital. Records of the administration of medicines were clearly made, although records of ‘flushes’ when administering medicines through an enteral tube were not recorded as consistently.

There were only limited opportunities for patients to self-administer medicines as part of their rehabilitation. We were told that on two wards (Albion Mill and Clitheroe Community Hospital) this was hampered by a lack of individual patient medicines lockers, although there were plans to imminently introduce lockers at Clitheroe and refresh knowledge of this policy for implementation across all intermediate care wards. Due to the service at Albion Mill being provided through a time limited partnership at the time we inspected, there were no plans to introduce lockers at this site. We were also told that there was a lack of staff to complete assessments for the use of monitored dosage systems should these be thought necessary to support safe medicines self-administration. Additionally, trust policy did not allow for the use of monitored dosage systems to support independence in the safe administration of medicines, should this be thought to be potentially helpful.

Pharmacy team support to the wards varied with, for example, mostly remote support being provided to Albion Mill and Clitheroe Community Hospital. Pharmacists were able to review prescribing electronically but relied on calls from the ward if other types of support were needed, such as advice about crushing medicines. There is a potential for this to reduce access to clinical pharmacy review to support medicines optimisation. We saw one example where the electronic system had not alerted the pharmacist to a new prescription of a high-risk medicine and another where a record did not indicate that advice about crushing had been sought. Following the inspection the trust told us that the clinical informatics team was notified of these errors and they were rectified immediately, with no harm being caused. We saw another example where specialist microbiology review of antimicrobial prescribing was delayed (by 4 days) due to a lack of capacity in microbiology. The risk of delays in supplying medicines on discharge and a more general safety risk relating to pharmacy staffing levels had both been identified by the trust on the risk register and were kept under regular review.

Medicines including controlled drugs were securely stored, however we found some examples where raised room or fridge temperatures had not been appropriately escalated. We found some medicines which had passed their expiry date still in active stock. The trust had a standard operating procedure for staff to check medicine expiry dates prior to administration and monthly checks for out of date medicines which both will have mitigated the risk of patients receiving an out of date medicine. The plug for the medicines fridge on ward 19 was not clearly labelled to prevent the fridge being accidentally turned off. However, following the inspection the trust confirmed that there had been no reported incidents of this occurring. We also saw occasional examples where good practice was not followed when amending entries in the controlled drugs register. The trust’s own medicines storage and controlled drugs audits similarly found shortfalls in some areas. This was being monitored to try to bring about improvement. We saw that medicines related incidents were appropriately reported for review.