Tees, Esk and Wear Valleys 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

The services showed evidence of a good learning culture, and people using the services told us that they felt safe. People were safeguarded by the staff caring for them. People had appropriate risk assessments in place which were regularly updated and people told us they, and their carers had been involved in creating them. People were cared for in environments which were clean and staff followed IPC procedures. The trust was aware of some environmental issues and were addressing these. However, the service did not always have enough staff with the correct levels of training and supervision. The training figures across all teams (apart from Scarborough Hospital Liaison) had multiple mandatory training with compliance figures of under 75%. This has also been listed on their risk register in the Durham, Tees Valley and Forensic Care Group since May 2023. The risk was due to be reviewed in May 2024 and following the review, the risk was due for closure. We were concerned about the management of medicines in some areas of the service. Staff on-site told us patient medicines were left in the staff office area of the crisis assessment suite at Roseberry Park Hospital and were not securely stored and the room was not temperate controlled as per policy. The clerking in process at the crisis assessment suite at Roseberry Park Hospital was not always clear and could lead to people using the service not having the correct medicines available.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Most people we spoke to had not been given an opportunity to feedback on the service they received. We spoke with 14 people who used the service. Although 1 person had been given a feedback form and another person was told the service would call them for feedback at a later date, 12 people and 2 carers said they were not told how they could feedback on the service they had received. Most we spoke to had never raised a complaint about the service, but 3 people who had raised complaints were not happy with either not getting a response or the response being generic. The trust had records of these complaints and told us that 1 concern was responded to via telephone and 2 were responded to via the trusts local issue resolution pathway which the trust defines as an “everyday conversation not a complaint” and as such formal complaint response letters were not sent. People’s views were taken into account and included in all patient safety incidents we reviewed.

Staff were generally positive about the trust’s learning culture however staffing issues did sometimes effect people’s ability to be present at opportunities for learning. Some staff told us they receive e-mails about any lessons learned and these are discussed further in regular meetings and supervision. They also said there was access to regular reflective practice sessions and debriefs. However, some staff at Roseberry Park did tell us that they did not have the time to always attend these. We reviewed a sample of staff meeting minutes for last 3 months for crisis, psychiatric liaison and health-based places of safety teams and although most teams were able to have a monthly team meeting, some had been cancelled due to staff sickness and/or high acuity of service. The trust had recently moved from one incident reporting system to another and staff told us that there had been no issues with this transition. Managers we spoke with had a good understanding of the incident reporting and escalation process for incidents. The trust had a Freedom to Speak Up (FTSUG) Policy and a Freedom to Speak Up Guardian, an allocated person who can support workers to speak up when they feel that they are unable to do so by other routes. The trust told us that from January 2023 to June 2024 there had been 955 reports about patient safety, however, these reports are for the whole of the Tees, Esk and Wear Valley Trust and its multiple services and locations. Staff we spoke to were aware of the FTSUG in their area and we saw posters in staff areas.

The trust managed patient safety incidents well. They completed serious incident investigations and outlined any learning to be shared which included the requirement for duty of candour letters to be sent out to people and their family members. Duty of candour is the requirement for services to be open and transparent with people who use services. In the last 12 months, there had been 18 Serious Incident Investigations completed which were linked to Crisis, health-based place of safety or Liaison Psychiatry within the Trust, where Duty of Candour applied. The trust uses the NHS Patient Safety Incident Response Framework (PSIRF) for the purpose of learning and improving patient safety. There are four key aims with regards to patient safety incidents: compassionate engagement and involvement of those affected; a system-based approach to learning; considered and proportionate responses; supportive oversight focused on strengthening response systems and improvement. During our inspection of the trust in 2023 we had found they had a significant backlog of 100 serious incidents requiring investigation. The trust has worked at pace to reduce their outstanding serious incident reviews and by June 2024, the backlog of serious incident reviews had been fully investigated and the trust had a sustainability plan in place to ensure the situation did not occur in the future. The trust had various ways to share learning to the teams, these included an all staff briefing and an online blog from the trust’s CEO. There were also governance and assurance meetings held regularly across the trust and locally.

People gave mixed views about how well teams worked together. Most of the people we spoke to said services communicated well with each other to ensure their continuity of care. However, some people said teams did not liaise well with each other and placed blame on other teams rather than coming to a resolution.

Staff told us they had effective working relationships with other relevant teams within the organisation and with relevant services outside the organisation. Staff said that people’s risks were shared between teams at regular handovers between staff. Teams liaised with external organisations, such as the police to discuss the needs of people who require more frequent care. Each person had risk assessments created which were regularly updated and re-assessed at regular intervals or at every meeting with the person. Staff told us that risks were assessed for people on the waiting list and support provided and concerns escalated if required. However, some staff did note that the lack of inpatient beds resulted in a patient being placed in a Section 136 Crisis Suite whilst awaiting an inpatient bed. The Crisis Assessment Suite at Roseberry Park hospital had a “walk in” option and staff said not all of the people who presented required mental health support but rather social support. They recognised there needed to be more integration between mental health services and social services.

Most of the external organisations we spoke to said the lack of Section 136 suites in their local area was an issue. Although there were suites available within the trusts geographical patch they said this could lead to long travel times to find an available suite that was outside of their local authority area. In the Durham, Tees Valley and Forensic Care Group area, some police partners felt they were attending to people where the responsibility for the person should lie with the trust and not all staff at the trust understood their duties, mainly due to the number of bank and agency staff used. They did acknowledge the effectiveness of the street triage role but said the staff were frequently taken off to cover the crisis team. The police had worked together with the trust to create policies and processes which had been positive for people’s care such as an initiative for people who required frequent crisis support in the area. They had implemented the national “Right Care, Right Person” initiative, which aims to ensure that people in a mental health crisis are not left without support. In North Yorkshire, York and Selby most police told us that trust staff being placed in the police control room and on street triage had been positive. However, they did note that there had been a reduction of trust staff available for street triage. Prior to the inspection there was a serious incident at the York and Scarborough Teaching Hospitals NHS Foundation Trust acute, which highlighted some potential issues for continuity of care between the hospital and the mental health team, but immediate work was undertaken to rectify the concerns. Most of the local authorities we spoke to said they felt left out of decisions, such as call handling response times, which meant they did not feel like teams were always effectively working together for a shared direction. Some also said that information was not always shared and there was a lack of handover between staff.

We reviewed a sample of care records for people who used the services. Most of the records we reviewed showed appropriate referrals being made and evidenced continuity of care with other organisations such as the local GP, autism services and the local authority. Teams held various daily huddles and multi-disciplinary meetings to share information regarding each person accessing the service. These meetings included risk formulation, agreement for referrals, and any safeguarding concerns.

Most of the people who had used the service told us that they felt safe. Eleven people out of 14 who had used the service and 2 carers told us they felt the service had kept them safe. Three people told us the service had not made them feel safe and 1 said they felt let down and their concerns weren't taken seriously.

All staff we spoke to across the trust had a strong understanding of safeguarding and how to take appropriate action. They were all able to say who they would contact and what referrals would be made. The trust had tools in place to assess not only the persons mental health needs, but also to assess the impact of that person’s mental health on any dependants. All staff could provide examples of when they have worked with external organisations to ensure appropriate support was provided to the person seeking help.

Staff understood how to protect patients from abuse. We observed a sample of interactions between staff and people using the crisis and health based places of safety services, the interactions included seeking consent for referrals and looking at ways to keep the person safe. A safeguarding allegation was made during one of the observations and we were told this had been followed up with a safeguarding and police referral.

The trust shared safeguarding information with colleagues through various routes such as the safeguarding bulletin and external organisation reports such as domestic abuse information. They had appropriate safeguarding policies in place and safeguarding leads across the trust. However, safeguarding training compliance was low in some of the teams. The trust’s Adult Safeguarding policy stated that “All concerns that meet the safeguarding adult requirements under the Care Act, (…), are to be raised with the Local Authority. The trust had raised 123 safeguarding concerns in the last year to their in-house safeguarding team and 50 of those had been further reported to the local authority. The remaining 73 were reviewed as per the trust’s safeguarding policy and managed within the trust. We reviewed the last 10 reports for safeguarding section 42 reports (the requirement for each local authority to make enquiries (or cause others to do so) if it believes an adult is experiencing, or is at risk of, abuse or neglect). The trust was last requested to lead on a report of this type in February 2024. We saw good practice including liaising with multiple external agencies. The trust could not tell us how many safeguarding alerts they had raised in the last 12 months which had progressed to a section 42 report. When the trust requested this information from their 8 local authority partners, they were told this information was not available or they did not get a response back. During our external organisation focus groups, most attendees shared that the safeguarding reporting processes and structures were unclear and they were concerned this may lead to missed reports or an under reporting of safeguarding concerns. However, the trust said they had not been informed of these concerns. The trust told us they had introduced a new system in February 2024 which would capture how many safeguarding concerns had progressed to a section 42 investigation.

Staff informed and involved families and carers appropriately. 11 of the 14 people who used the services and all 3 carers we spoke to said they were involved in the planning of care for them or their relative. We observed interactions between staff and people calling the crisis line and also in person and risk was mostly responded to appropriately.

Staff assessed and managed risks to patients and themselves. Staff told us that they always review the risks for people and refer them to appropriate agencies as required. All people who contacted the crisis and health based places of safety services are supported via the use of a triage tool to ensure all of their risks can be understood and supported. This included the views of carers and relatives and ensuring the person was involved in all decisions. Staff told us that when working in the emergency department, if a restraint was ever needed this would be done by hospital security staff and all staff carried alarms. The patient liaison psychiatry teams had also provided training on people in mental health crisis to external organisations including the police. Staff told us restraint in the section 136 suites was very rare. Risk assessments are completed to see if people are at risk of restraint with a focus on verbal de-escalation.

The trust responded promptly to sudden deterioration in a patient’s health. When necessary, staff working in the mental health crisis teams worked with patients and their families and carers to develop crisis plans. Of the 49 care records we reviewed, we mostly saw that safety plans had been completed and updated appropriately for any risks identified. We saw evidence that people, carers and relatives were involved in risk management and appropriate external organisations were referred to. However, during our review of care plans in the Durham and Darlington Crisis team we saw that for one person there was a risk assessment in place but no management plan in place on how to mitigate against those risks.

All clinical premises where patients received care were well equipped, well furnished, well maintained and fit for purpose. All people and carers we spoke to who had accessed the services locations said it was comfortable and accessible.

Staff told us that their working environments did not always ensure they felt safe. Most staff we spoke to had concerns about how people and staff will be kept safe when using the section 136 crisis assessment suite at Roseberry Park. This was mainly in reference to people using the suite whilst awaiting an inpatient bed, and others using the communal waiting area who may be there for varying reasons and in various stages of crisis. Some staff said these issues wouldn’t be there if there weren’t inpatient bed pressures. We raised this with the trust who advised that risk assessments and engagement with people and third parties were used to assess any risk and mitigated against usually with staff presence and CCTV.

During the assessment we observed that whilst the majority of environments met safety requirements, some needed renovation. We reviewed the rooms at the emergency departments which were used for mental health assessments of people in a mental health crisis and the respective annual environmental audits which met required standards. The Section 136 suites we reviewed were within the requirements of the Mental Health Act, however, at Cross Lane Hospital the doors to access the toilets in the section 136 suites were locked at all times. Staff told us this was because the area was a blind spot. The trust told us that 2 members of staff are present at all times and could unlock the door if a patient needed access. The Section 136 suite at Cross Lane hospital had no intercom system in place, we raised this with the trust who fitted an intercom in June 2024. The police entrance to this suite was also located in the main hospital car park which did not protect the privacy of people accessing the service. We raised this with the trust who installed fencing. The section 136 crisis assessment suite at Roseberry Park Hospital had 2 people in the communal area at the time of our assessment. We had concerns that a male patient who was detained under the Mental Health Act was in the communal area which could also be accessed by a female who was not detained. We raised this with the trust who advised risk assessments had been completed to ensure the safety of both people and staff. Blind spots within the suite had not been mitigated by CCTV or mirrors but the trust told us this was being looked at under governance processes. All of the locations we visited had appropriate environmental audits in place. In Lanchester Road section 136 suite there was a programme of estate works being completed as a result of these audits, including ensuring all fixtures and fittings were anti-ligature (something used for tying or binding something tightly) as some of the items were not currently.

The trust had appropriate policies in place to ensure safe care and treatment in the environment and across systems. These included a fire safety policy and a risk assessment policy.

The service generally had enough nursing and support staff to keep patients safe. Ten out of 14 people and 3 carers said there was enough staff to meet the persons needs and were able to respond to any concerns raised. One person told us that there were no psychologists available on a weekend and during our assessment, however, the Crisis Resolution Home Treatment Teams met the national Quality Network Crisis Resolution Home Treatment Team (QNCRHTT) Standards and Psychological Wellbeing Practitioners undertook psychological interventions at the weekends.

The services did not always have enough staff to keep people safe from avoidable harm. The trust told us that they had no instances where an appointment had been cancelled by the trust but some staff told us that this did happen when they were short staffed and phone calls were done instead of home visits. The trust told us following this staff feedback that these would only be done by a suitable practitioner following a risk assessment. Staff in the York Crisis team told us that there had been no consultant psychiatrist for a long period of time. The trust told us that the team had an experienced nurse consultant who was also an approved clinician during this time. The Darlington and Durham crisis teams were in business continuity due to high vacancies and staff told us there were regular calls about this and senior clinical staff could stand in to support if needed. Some staff told us that staffing the crisis assessment suite at Roseberry Park Hospital on a night could be difficult. However, there was a medical on-call rota that covered all sites out of hours. Although all staff we spoke to said they received good, consistent supervision the recorded rates for clinical and managerial supervision rates were below 75% in 3 teams. Appraisal rates for staff were between 78% and 100% across all teams.

Staff we observed were able to give each person using the service the time they needed. We observed people receiving care over the telephone, in Section 136 suites, during assessments at the acute hospitals and home visits. We observed multi-disciplinary meetings where all staff were involved in discussions to ensure the best care for each person and daily team huddles where staff were kept up to date on each person’s care from the previous 24 hours and care was handed over from team to team.

There was not always enough staff with the right training. The trust had low levels of staffing in some teams and had business continuity plans in place. Staffing issues had been escalated to the trust risk register. The most vacancies were in the Durham and Darlington Crisis teams and the York and Selby Crisis teams. The trust supplied us with vacancy data which gave a 17.4% vacancy rate across all of the teams. The number of shifts between December 2023 and May 2024 not filled for each team varied from the highest at 671 shifts in Durham and Darlington Crisis team and 204 shifts in the York mental health liaison team. All staff were provided with a comprehensive induction. The services had an average sickness of 5.32% from April 2023 to May 2024. The lowest was 1.99% at the Scarborough Hospital Psychiatric liaison team, and the highest was 8.04% in the Durham and Darlington crisis teams. Staff turnover rates were variable. The highest were 14.24% at the York and Selby crisis team, 12.91% at the Darlington and Durham crisis team, and 11.39% at the UHND psychiatry liaison team. From Dec 2023 to May 2024, the trust had used 7 individual bank and agency staff and they were used most in the York and Selby crisis and intensive home treatment team for 356 shifts and the Durham and Darlington Crisis team for 119 shifts. Clinical supervision rates were lower than the trust’s target in some teams, with the lowest in the York Teaching Hospital Psychiatric Liaison team at 43%. Managerial supervision was also low across some of the teams. Across all teams (apart from Scarborough Hospital Liaison) multiple training courses had compliance figures of under 75%. We were concerned that training courses which posed a risk to patient safety were incomplete, for example, resuscitation immediate life support was at 0% in the Durham and Darlington crisis teams, the Teesside Crisis Triage and Assessment Hub and the York and Selby Crisis Intensive home treatment team.

All clinical premises where patients received care were safe and clean. All people we spoke to who had accessed the providers services said they were clean and well maintained.

All staff we spoke to were aware of infection control procedures and could locate appropriate equipment, such as personal protective equipment (PPE). At the crisis assessment suite at Roseberry Park Hospital, we saw people’s food being prepared in the small staff kitchenette. We were told this was due to there being no formal food provision for people admitted to the suite other than microwave meals. We raised this with the trust who advised us that people also have access to sandwiches via an adjoining ward and meals which can be heated and accessed at all times.

The physical environment of the health-based places of safety met the requirements of the Mental Health Act Code of Practice. Of all the trust’s locations we reviewed we had no concerns about cleanliness. We saw staff using appropriate infection prevention procedures.

The trust had appropriate policies in place to assess and manage the risk of infection. These included a waste management policy, outbreak infection policy and infectious diseases procedure. The trust completed annual infection prevention control audits.

People told us that staff reviewed patients' medicines regularly and provided specific advice to patients and carers about their medicines. The majority of both people who have used the service and carers we spoke to said they had medicines prescribed by the crisis team and said these were regularly reviewed and advice was given.

The service did not always use systems and processes to safely prescribe, administer, record and store medicines. Staff told us that the Durham crisis team were not currently stocking medication due to issues with the recording and checks of medicines. The teams had enough staff members who were able to prescribe medicines but said there was an issue accessing medicines due to there being no “on call” pharmacy. We were given examples of various times people had to travel long distances to be able to access the medicines. We raised this with the trust who confirmed there is a dedicated out of hours pharmacy provision and staff may not know the process. At the crisis assessment suite at Roseberry Park Hospital there was no process in place for managing medication for patients who were “bedded down” without formal admission. Conflicting advice was given about whether all people should be clerked in which meant not all people had their medicines appropriately documented and stored. Most staff told us that the medicines for these people were usually left on a side in the office. The trust has now installed lockers where people can store medicines safely. The trust’s medications management policy stated, “Any medicines supplied must be stored in a temperature controlled and monitored secure room in the 136 suite or on an adjacent ward to be identified at each site. This should also include any patients’ own medication that has been assessed as suitable for use. The decision as to where medicines are to be stored should be risk assessed as transporting medication from a ward to the s136 suite could represent a significant risk to the nurses involved in transporting and administration.” Staff were unclear what the process was for storage of medicines and felt uncomfortable with them being ‘stored’ in an open staff area. Staff told us they were kept up to date about people’s medicines from third party organisations who were also involved in each person’s care.

The service had systems to ensure staff knew about safety alerts and incidents, so patients received their medicines safely. The care records we reviewed showed medicines information had been recorded along with any allergies for each individual. We observed staff speaking to people about medication that would be prescribed and information being provided about what the medicine was for and any possible side effects. This information was also provided in a medication information leaflet. The trust did use patient group directions for some medications that may be administered by the crisis teams. Patient Group Directions (PGDs) provide a legal framework that allows some registered health professionals to supply and/or administer specified medicines to a pre-defined group of patients, without them having to see a prescriber (such as a doctor or nurse prescriber). We completed a review of these at Teesside crisis services and found each medication had been appropriately signed for and the trust had an up to date policy on PGD use.

There was not always appropriate policies and processes in place to ensure people in the crisis assessment suite had their medicines safely. The trust had numerous policies in place around the safe use of medicines, including the medicines overarching framework policy. The Trust’s Prescribing and Administration of Medication in Section 136 suites policy stated that “detention under section 135 or 136 can be for up to 24 hours with the possibility of extension for an additional 12 hours in particular circumstances. There is a need to reconcile and provide medication to patients in the suites, in particular critical medicines, as lack of access to such medication could have significant impact on their physical health.” However, we had seen that not all people were appropriately clerked in to the crisis assessment suite at Roseberry Park and this had left a gap for a process for medicines for those people. The trust’s provided a flowchart for the health based place of safety and admissions of detained patients when there are no inpatient beds available. This stated that in this situation patients should be clerked in by a doctor. Staff we spoke with told us this was not always done as the messages about clerking patients in were not clear. Staff gave an example of a patient recently who was not clerked in and it was later discovered they were epileptic. As they had not been clerked in, any necessary medicines would not have been available should they have had suffered a seizure. The trust website had patient information leaflets online for all medications that people could access.