Tees, Esk and Wear Valleys NHS Foundation Trust

Updated 25 October 2023

Tees, Esk and Wear Valleys NHS Foundation Trust provide mental health and learning disability services in County Durham and Darlington, Teesside, North Yorkshire, York and Selby. The trust have 167 services across 66 locations. The trust provide 10 core services:

• Specialist community mental health services for children and young people
• Community mental health services with learning disabilities or autism
• Community-based mental health services for older people
• Community-based mental health services for adults of working age
• Mental health crisis services and health-based places of safety
• Wards for people with a learning disability or autism
• Forensic inpatient or secure wards
• Long stay or rehabilitation mental health wards for working age adults
• Wards for older people with mental health problems
• Acute wards for adults of working age and psychiatric intensive care units

The trust also provide one specialist service.

We carried out unannounced inspections of 4 of the inpatient mental health services provided by this trust, and short notice (24 hours) announced inspections of 2 of the community services.

We also inspected the well-led key question for the trust overall.

We inspected acute wards for adults and psychiatric intensive care units and community mental health services for adults of working age because we had concerns about the quality of care provided relating to serious incidents occurring in the services.

We inspected inpatient wards for people with a learning disability and or autism because at our last inspection in 2022 we rated the service as inadequate overall and needed to ensure the quality of care had improved.

We inspected inpatient forensic secure services because at our last inspection of this service in 2022, we rated this service requires improvement overall and inadequate in the safe key question and needed to ensure that the quality of care had improved.

We inspected wards for older people with mental health problems and community mental health services for people with a learning disability or autism because of the length of time since we last visited these services and due to the potential high-risk nature of these services.

We did not inspect long stay/rehabilitation mental health wards for working age adults, mental health crisis services and health-based places of safety, or community-based mental health services for older people because we have not been in receipt of information of concern since our last inspection of these services.

We did not inspect specialist community mental health services for children and young people because the services had not had time since our last inspection to make the improvements necessary to meet legal requirements as set out in the action plan the trust sent us after the last inspection.

We are monitoring the progress of improvements to these services and will re-inspect them as appropriate.

Overall, we rated safe, responsive and well led as requires improvement and effective and caring as good.

Our rating of the trust stayed the same. We rated them as requires improvement because:

• At this inspection we rated 3 of the six services core services we inspected as requires improvement overall and 3 as good. In rating the trust, we took into account the current ratings of the four services we did not inspect this time.
• We rated 7 of the trust’s 10 core services and one specialist service as good and 4 as requires improvement. We rated 9 core services as requires improvement in the safe key question and 5 as requires improvement in the responsive key question. We found effective leadership and management at local level in most services, however we found that some of the trust’s systems and processes did not operate effectively at a senior level. This meant that whilst we rated well-led as good in most core services, we rated the trust as requires improvement for the overall well led key question.
• The trust did not always have enough suitably trained staff to deliver safe care in all services. This was due to high vacancy rates, high sickness rates and significant reliance on temporary staff in some services. There was low compliance with specific modules of mandatory training. This included modules directly related to patient safety such as moving and handling, positive and safe care (restraint) and resuscitation.
• Some areas of the trust’s estate continued to present risks to quality and safety. Action plans to remove environmental ligature risks had not all been completed. Seclusion facilities were not always fit for purpose. Some wards had blind spots which had not been identified or mitigated, the trust acted on these at the time of the inspection.
• The trust’s reducing restrictive practice programme for 2022-23 had failed to reduce overall rates of restraint. The use of restraint had increased by 17% in the trust’s services since the previous year. The trust continued to use prone and mechanical restraint without appropriate challenge and oversight by senior leaders. However, there had been a reduction in the use of prone and supine restraint, with an increase in less intensive forms of restraint.
• Staff did not always consistently take appropriate action to reduce risk to people using services. Some patients in acute mental health services were able to access leave from wards without appropriate risk assessment. Some patients’ physical health was not always monitored appropriately in acute mental health, forensic and learning disability inpatient services. Risks were not always shared and handed over effectively between shifts on some wards.
• People continued to wait too long to access services. Waiting times for community mental health services had not improved since the last inspection. There were significant waiting times in child and adolescent mental health services and for neurodevelopmental assessments. The trust’s locality model had introduced variation where some patients faced inequity of access to services because of where they lived. The trust needed to work with both integrated care boards to improve access to services.
• Staff did not always receive, or record that they had received regular supervision and appraisal. This meant that the trust did not have effective systems in place for oversight of whether staff received appropriate opportunities for support and development.
• The trust did not have effective systems to consistently collate, analyse and present information about quality and performance in a way that identified risks and challenges, or supported effective decision making. There were examples of early warning signs in frontline services which had been missed by the trust’s risk management and audit processes.
• The trust had a backlog of 100 serious incidents requiring investigation. There were further backlogs in incidents requiring routine investigation and in incidents resulting in patient deaths requiring review through the trust’s learning from deaths processes. The trust’s backlogs delayed opportunities to learn lessons and make improvements to prevent incidents recurring. The trust had experienced several similar incidents where learning was not evident. The trust were receiving external support to manage the incident backlog.
• The trust had experienced several high-profile incidents. The impact of the incidents had resulted in lasting and persistent changes to the culture of the trust which included an over-cautious approach from senior leaders to recognise and celebrate improvement.
• Where there had been incidents or treatment which caused harm to patients, the trust’s approach had not always ensured staff and leaders reached out to people who had been harmed by its practices. The trust missed opportunities and appeared reluctant to consistently engage with people who used services, staff and others who had negative experiences or had been involved in incidents.
• The trust did not always act in accordance with the requirements of the duty of candour by failing to make an apology without delay for incidents resulting in harm.

However:

• Forensic inpatient secure wards, wards for people with a learning disability or autism and wards for older people had all improved since our last inspection. The trust no longer had any services which were rated inadequate. The leadership and safety of community mental health services for working age adults had improved since our last inspection in December 2021 and ratings had improved to a rating of good overall.
• Leaders were experienced, visible and approachable. Leaders at all levels had ensured that improvements were made since our last inspection. The trust had made improvements to its fit and proper persons’ process.
• Executives and non-executives were passionate about the trust’s delivery of safe, high-quality care and were aware most of the trust’s challenges, risks, and issues.
• The trust had a clear vision and strategy, understood by all staff and driven by the chief executive. We were able to see progression towards the trust’s achievement of its strategic goals. Staff demonstrated the trust’s values in the care they provided.
• Staff felt supported and valued and had confidence in the trust’s freedom to speak up process. The trust had undertaken work to understand the risks of closed cultures across the services it provided.
• The trust was making improvements to its information management systems which included a refreshed patient record system which had been co-created with staff, service users and carers and was clinically designed.
• There continued to be good and improved engagement with staff, stakeholders, and partners. The trust was ambitious about co-creation and had several programmes in place to enhance opportunities for involvement.
• The trust had implemented a recognised methodology with a clear and embedded approach to quality improvement which involved staff at all levels, we were able to see examples of where quality improvement approaches had been used to improve services and processes. However, we saw that the trust's approach to quality improvement was sometimes related more to problem solving than innovation.

• The trust had sought feedback on its governance processes and had made significant changes to governance arrangements which had made it easier for services to escalate risks to the board

How we carried out the inspection

Before the inspection visit, we reviewed information that we held about the trust. During the inspection visit, the inspection team:

• visited all 42 of the trust’s forensic inpatient secure wards, acute wards and psychiatric intensive care units, wards for older people and wards for people with a learning disability and autism.
• visited two of the trust’s learning disability respite units.
• visited 14 of the trust’s community locations.
• spoke with 292 members of staff.
• spoke with 131 people using the trust’s services.
• spoke with 31 carers or relatives of people using the trust’s services.
• reviewed 217 care records including 115 medicines administration charts.
• carried out 6 short observational framework for inspection (SOFI2) observations.
• observed several meetings including multi-disciplinary team meetings and safety huddles.
• observed four sub-committees of the board as well as one board meeting.
• held three focus groups with staff and governors.
• spoke with 25 members of the trust’s leadership team including members of the board, the chair and the chief executive.
• sought feedback from a range of stakeholders including health watch and the integrated care board.
• reviewed the trust’s process for fit and proper persons employed.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

In wards for older people with mental health problems.

Patients told us that staff were kind and considerate and that they were always around to support them whenever they needed. They said that staff managed very well at busy times, and they said that they dealt with difficult situations very well. Patients said they felt safe whilst they were being cared for on the wards. Patients told us that the wards were always kept clean and that they felt the facilities met their needs. They said that they valued the range of support available and sessions and activities that were taking place. They said that food and drinks were good quality and available at all times.

In forensic secure inpatient wards.

Patients talked positively about the activities they were involved in including cooking, drama, pet therapy and fitness. Patients told us staff were supportive and kind and that they felt safe on the wards. One patient talked about the comprehensive support they were receiving in their transition to their future placement. Another patient talked about the service meeting their cultural and faith needs and facilitating access to the Imam.

In wards for people with a learning disability or autism.

People told us staff were friendly and nice. They told us staff supported them to carry out activities that were of interest to them. People showed us their accommodation and described how they had personalised it. One person was happy to tell us about their future plans. Relatives and carers of people using the service told us that environments were clean and fit for purpose. They told us people usually had a stable staff team who knew and understood the person well. They told us they felt their relatives were safe using the service. One family member told us there had been a significant reduction in the number of incidents involving their relative. They told us people received high standards of person-centred care.

In acute wards for adults of working age and psychiatric intensive care units.

Patients were mostly positive about the care and treatment they received. Most patients told us that staff were very friendly, kind and supportive and were very complimentary about the quality of care they received. They told us that staff always treated them with dignity and respect. Most patients told us that staff were responsive to their needs and had regular 1:1s with nursing staff.

Most patients were very complimentary about the quality and choice of the food available.

Patients told us they had access to activities during weekdays.

Patients felt involved in their care and treatment and that staff involved their carers as appropriate.

In community services for people with a learning disability or autism.

Patients told us they were actively involved in discussing and planning their care needs along with their social care needs. One patient told us their care was “really really good, I like my nurse and psychiatrist”. Other patients told us that the service “couldn’t be better” and was “great”. Carers and relatives told us that the service helped them identify what support was available for them and their relative and the team “moved heaven and earth for us”.

In community mental health services for adults of working age.

Patients who used the service told us they were actively involved in coproducing, writing, and planning their care and were involved in decisions about their care and treatment. One patient told us their care support worker was ‘better than therapy, or medicines’. Another patient told us ’I’m striving, not surviving and feel valued’. Other patients told us that the service “did what it said on the tin and exceeded my expectations’ and ‘the service saved my life’. Carers and relatives told us that the service supported them, and they had access to carer support champions and could attend carer support groups.

Trustwide

We reached out to the trust’s stakeholders to give feedback for the inspection and received it from Healthwatch York.

Healthwatch York noted that in children’s services more recently they had been hearing and receiving positive feedback on the service including improved communication with parents, improved information and signposting in the letters parents receive when their referral has been acknowledged.

Healthwatch York also shared that they had noted a recent willingness from the trust to help them understand more about their approach to service provision and a want to link Healthwatch York to people around the system. Healthwatch York had been invited to speak to the trust about their mental health crisis care work, including the invite to host conversations with the crisis team staff. They also noted that leadership within the trust had been open to conversations around needs for improvements and the challenges they were facing.

They shared some positive comments from patients and staff in relation to quick responses from the crisis team and improved access to the crisis team’s telephone in York.

However,

In community mental health services for adults of working age

Patients said getting through to teams in York and Middlesborough was difficult, because the phone lines were constantly busy.

Some patients told us that the trust’s approach to care did not feel person centred and inclusive.

In forensic secure inpatient services

We spoke with 41 patients. One patient told us that staff did not understand their needs, particularly unfamiliar staff and this meant that staff misinterpreted their communication. Eleven patients told us that the food was of poor quality. Seventeen patients told us the staffing levels were low, this impacted on them being able to pursue activities, access leave and have the staff support that they required. Patients on Brambling ward told us that they couldn’t use the safes in their rooms, either because they were broken, or staff had not helped them to set them up. A patient told us and records confirmed for another patient that they had not received a debrief following incidents. Four patients told us that some staff do not protect their privacy and dignity by entering their room without knocking.

In wards for people with a learning disability and autism

Two family members raised concerns about the number of agency staff working in the service. One family member said there weren’t enough meaningful activities.

In acute wards for adults of working age and psychiatric intensive care units.

We spoke with 47 patients. Six patients told us that staff could be busy, they told us that sometimes nurse staffing levels caused delays in dealing with requests specifically those that needed the support of a registered nurse. 10 patients across all the sites told us they did not know who their named nurse was and/or they were not having proactive regular and meaningful 1:1 conversation with nursing staff to talk about their mental health, wellbeing and progress. They reported that this was due to nursing staff being too busy as the wards were short staffed. Patients did say if they asked to speak to a nurse themselves this was facilitated.

They told us that there was less to do in the evenings and at weekends. Some patients told us that there was too much focus on physical activities such as walking and going to the gym. Some patients were not aware of the activities available as there wasn’t always an updated activities timetable.

One patient told us that staff had refused to follow a specific aspect of their care plan and that this had caused them distress, they also told us that they were not given a copy of their care plan and information about their rights.

Trustwide

Healthwatch York told us that in children’s services there continued to be a need for improved communication around services available to help with ‘waiting well’ and prevention. Also, a need to address inefficient administration systems.

They told us that findings in March 2023 in relation to care of older people with mental health problems suggested; discrepancies in diagnostic wait times, discrepancies in experiences of health care and a lack of coordination between providers, concerns around how ‘user friendly’ accessing support can be, lack of formal information and guidance support. They said that the public and partners told them about ‘blockages’ at every stage of the diagnosis process.

Updated 3 March 2020

We rated it as good because:

• The service provided safe care and treatment for patients under its care and there were enough nurses and doctors to facilitate this. The ward environment was safe and clean. Staff assessed and managed risk well. They minimised the use of restrictive practices and managed medicines safely.
• The staff team included or had access to the full range of specialists required to meet the needs of patients. Managers ensured that these staff had access to training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward including community teams who would have a role in providing aftercare.
• Staff developed comprehensive holistic, recovery-oriented care plans which were informed by a comprehensive assessment which involved a number of professionals. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

• Though there were clear processes for reviewing incidents and complaints, the awareness of three of the staff we spoke with about lesson sharing was limited.
• Though risk management plans were captured through individual patient risk assessments, the ligature risk assessment used by the service did not include management plans for each risk or detail contingencies respectively on the ward ligature risk assessment.

Updated 15 September 2022

We carried out this unannounced focused inspection to see whether improvements had been made since our last inspection in June 2021. On that inspection, we issued a warning notice under Section 29A of the Health and Social Care Act.

On this inspection, we checked whether improvements had been made to address the concerns identified. These included, ensuring there were enough staff to meet the demands of the service, staff were appropriately trained, waiting lists were managed, there was clear oversight of any patient risks, the service could be accessed promptly and any issues were promptly addressed by senior management. This is in line with our published guidance to follow up inadequate ratings and section 29A warning notices.

The service provides specialist community mental health services for children and young people. We inspected the following teams:

• Easington Community Team
• CAMHS North Durham
• CYPS Getting More Help Stockton
• CYPS Getting More Help Middlesbrough
• CYPS Scarborough
• CAMHS York East and West

We provided 24 hours’ notice of the inspection to ensure someone would be available at each of the team bases. We inspected on 6-7 July 2022. This was a focused inspection looking at the safe key question only. Our rating of this core service improved. We rated them as requires improvement because:

• Although improvements had been made since the previous inspection, there were still not enough staff in every team to meet the demands of the service. Some teams still had a high number of vacancies and high caseloads.
• Not all staff were appropriately trained in the mandatory skills required to fulfil their roles.
• Despite improvements made, some children and young people were still waiting a long time for treatment.
• The majority of children and young people had safety plans in place but where safety plans hadn’t been created, there wasn’t always justification recorded for this.
• Staff did not have access to personal alarms at North Durham and not all rooms at Middlesbrough and York were sound proofed.

However:

• The service was achieving its targets of maintaining contact with children and young people on waiting lists.
• The premises were clean, well maintained and well furnished.
• We found the trust senior management team had responded promptly to address issues identified at the previous inspection and in the section 29A warning notice. However, this work was ongoing and had not been fully embedded in the service.

How we carried out the inspection

On this inspection, we assessed whether the service had made improvements in response to the concerns we identified during our last inspection. We therefore only looked at the safe key question.

Before the inspection visit, we reviewed information that we held about the service. During the inspection visit, the inspection team:

• visited six team bases;
• reviewed the quality and safety of the environment;
• attended six meetings;
• spoke with 48 members of staff, including team managers;
• reviewed 47 care records;
• spoke with one young person and 19 parents or carers;
• looked at a range of audits, policies, procedures and other documents relating to the running of the service.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

We spoke with one young person and 19 parents or carers.

Everyone we spoke with told us staff treated them with respect and spoke with them in a way they could understand. They told us they always saw the same member of staff and clinicians could be accessed quickly when needed.

Most of the parents, carers and young people we spoke with told us they did not have to wait long for treatment. Four told us they waited longer than two months.

Parents, carers and young people told us the facilities were clean and comfortable.

Updated 25 October 2023

Updated 3 March 2020

Our rating of this service stayed the same. We rated it as good because:

• The service provided safe care. Clinical premises where patients were seen were safe and clean. The number of patients on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff managed waiting lists well to ensure that patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• The service was easy to access. Staff assessed and treated patients who required urgent care promptly and those who did not require urgent care did not wait too long to start treatment. The criteria for referral to the service did not exclude people who would have benefitted from care.
• The service was well led and the governance processes ensured that procedures relating to the work of the service ran smoothly.

Updated 10 December 2021

Updated 25 October 2023

Updated 25 October 2023

Updated 3 March 2020

Our rating of this service stayed the same. We rated it as good because:

• The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients cared for in a mental health rehabilitation ward and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed.
• The service worked to a recognised model of mental health rehabilitation. It was well led and the governance processes ensured that ward procedures ran smoothly.

However:

• Patients on Talbot ward did not have access to call alarms although the trust told us these would be installed during January 2020.
• At the Orchards, patients could not access take home medication when they went on leave unless it had been planned.
• On Oakwood it was not clear how staff identified medicines when the shelf life had been reduced due to high fridge temperatures.
• On Oakwood and Talbot wards, some patient care records contained the wrong ward names.
• At the Orchards, patients could not operate the vistamatic window from inside the room. This meant their privacy and dignity may be compromised.
• On Willow ward, we found little evidence of therapeutic activity.
• On Willow ward, care plans focused on patients’ immediate support needs with no connection to a longer-term formulation of what was necessary for discharge.

Updated 25 October 2023

Updated 25 October 2023

Updated 25 October 2023