Cheshire and Wirral Partnership 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

We assessed a total of 5 quality statements in the safe key question and found areas for improvement. The scores for these areas have been combined with scores based on the rating from the last inspection, which was good. Our rating for this key question is requires improvement. We identified a breach of regulation due to low supervision and appraisal rates. Safe systems, pathways and transitions were seen in practice with a new ‘First Response’ model introduced early in 2024. A central crisis line was the point of contact for patients to access services. Patients could be assessed in emergency departments by liaison psychiatry staff or supported by home treatment teams. These teams collaborated well with staff in the accident and emergency departments. In addition patients could be referred onto third sector organisations (voluntary/charities/private ) for support including crisis cafes and respite beds commissioned by the Trust. Staff worked well together with acute trust staff completing side by side assessments and liaison psychiatry completing initial assessment within 30-60 mins of a patient’s arrival in accident and emergency and if further mental health assessment or support was required. Trust staff worked with Cheshire police and Merseyside police street triage was implemented differently across the Trust geographical footprint. At the time of the inspection the Trust was about to introduce a joint service with North West ambulance service. There were effective systems and processes to protect people from abuse and neglect. Staff had received the required levels of children and adult safeguarding training appropriate to their role.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

People we spoke with had engaged with different services within the crisis care pathway. People were aware of the crisis line to call as the first point of contact for referral and or advice and were referred or signposted to relevant services based on the triage process. This included liaison psychiatry, home treatment teams, community mental health teams and third sector organisations (voluntary/charity/private), for example, crisis cafés and other community support.

The Trust commenced the ‘First Response’ model early in 2024, which was aimed at diverting people away from accident and emergency departments and provide the least restrictive options to have people's mental health assessed. The central contact points were crisis line and people could be seen by liaison psychiatry and home treatment teams. Feedback from Trust staff was the model worked well with accident and emergency staff, who could] refer patients onto third sector organisations (voluntary/charities/private) for support including crisis cafes and respite beds commissioned by the Trust. Trust staff worked with Cheshire police and Merseyside police, with a street triage team created and working across the Trust geographical footprint. A mental health ambulance service was also planned to start soon, where Trust staff would be working jointly with the local NHS ambulance services in assessing people at their place of crisis and not having to wait in accident and emergency departments.

Feedback from Cheshire police was the street triage service provided a trusted assessment, and in terms of people’s admission process was part of a 'first response’ service, the assessment process was not required to be repeated. If a person was not safe to stay in the community they would be taken to the accident and emergency department for safety, where the street triage would refer the person onto the home treatment team to follow up the assessment and support the person in crisis.

The 'first response’ model incorporated the crisis line, liaison psychiatry and home treatment teams, with clear and accessible referral pathways. Staff worked well together with acute trust staff completing side by side assessments and liaison psychiatry completing initial assessment within 30-60 mins of a patient’s arrival in accident and emergency and if further mental health assessment or support was required. General practitioners and the police could ring the crisis line for advice and support.

People were supported to understand safeguarding, what being safe means to them, and how to raise concerns when they don’t feel safe, or they have concerns about the safety of other people. During our engagement calls with patients and carers, no safeguarding concerns raised by or indicated by patients or carers. Patients and carers were aware as part of their assessment process they were asked questions relating to safeguarding and could report these to trust staff. Information provided to patients included indicators of abuse and local authority contact numbers if they needed advice, guidance or to make a referral.

There was a commitment to taking immediate action to keep people safe from abuse and neglect. This included working with partners in a collaborative way. Staff had safeguarding training, and were aware of safeguarding concerns and took action to escalate these. Where two organisations were involved, for example, the Trust and acute trust, information was shared between these organisations to make sure concerns were not missed and appropriate systems and processes were followed.

There were effective systems, processes, and practices to make sure people were protected from abuse and neglect. Patients' care records contained information of safeguarding concerns being identified, recorded and action taken. The Trust monitored safeguarding information and over the last 6 months, the most common themes identified were related to domestic abuse, financial abuse, sexual abuse, potential harm to others, modern slavery, and neglect. Safeguarding systems, processes and practices meant people’s human rights were upheld and they were protected from discrimination. People were supported to understand their rights, including their human rights, rights under the Mental Health Act, Mental Capacity Act 2005, and their rights under the Equality Act 2010.

Patients accessed services when required and knew who to contact if they had concerns about their mental health deteriorating. Relatives' feedback was if they or their relative accessed services then relatives knew who to contact if they had concerns. People participated in identifying risks and how to keep themselves safe.

There was a balanced and proportionate approach to risk that supported people and respected their choices they made about their care. Trust staff informed patients about any risks they identified and how to keep themselves safe. The Trust used the 5Ps as a risk assessment tool (Presenting problem, Predisposing factors, Precipitating factors, Perpetuating factors, and Protective factors). Risk was reassessed at each stage of the patient's journey through the service. Trust staff were informed about risks to and from patients through safety huddles, safety bulletins and staff meetings. Risks were assessed, and people and staff understood them. Liaison psychiatry staff carried out an initial risk assessment as part of side-by-side process, and a fuller assessment if a patient needed further assessment. Safety plans were formulated. The trust had policies on the use of restrictive practices (restraint, rapid tranquilisation, etc) but these were not used by Trust staff in the crisis pathway. Psychiatry liaison teams could advise acute trusts about this in accident and emergency departments.

Patients and relatives understood the processes to access services when required. Patients knew the processes to follow if they had concerns and or information on how to contact services. Patients could develop crisis plans and usually had a verbal safety plan, and would agree arrangements about the frequency of contacts and visits. Patients were aware of how referrals and or access to other services were made.

People were not always cared for in safe environments that were designed to meet their needs. Two of the 9 patients we spoke with commented on the environment in accident and emergency mental health rooms (health based places of safety) whilst waiting for assessment. (Note: Acute trusts provide accident and emergency services and therefore mental health rooms. The services referred to were located at Cheshire East and Cheshire West acute hospitals, where patients noted condition of these the rooms as poor.

Staff acknowledged that interview rooms for patients were not ideal, and standards varied from site to site. There were plans to improve facilities across acute hospital accident and emergency services and the Trust's staff offices/areas, which had limited facilities on some sites. Liaison psychiatry staff did not have personal alarms when working in accident and emergency departments, where there were alarms in some rooms, Liaison psychiatry staff would work in pairs if they had concerns about risk to themselves or would seek support from acute trust security staff, who they described as supportive.

There were effective arrangements to monitor the safety and upkeep of the premises. We identified concerns with the environment for both staff and patients. The health-based places of safety and mental health assessment rooms do not fully meet requirements. The rooms did not always have a call bell / alarm or fit for purpose furniture. The rooms did not always provide a safe or therapeutic space to manage patients experiencing mental health crisis. We will also provide this feedback to NHS acute partners. (Note: Acute trusts provide accident and emergency services and therefore mental health rooms. The services referred to were located at Cheshire West and Cheshire West acute hospitals. Home treatment team offices had variable facilities, though systems in place for staff to work safely.

Leaders and staff consider how environments could keep people safe from psychological harm as well as physical harm, for example in relation to sexual safety and in relation to sensory needs. The Trust had plans for improvements to assess patients in more suitable environments and were in the process of building urgent assessment centres where most patients who needed a mental health assessment (without physical health needs) would be seen. These buildings were at various stages of construction across the Trust geographical footprint. There were plans to improve existing accident and emergency services and work had already been completed on some acute sites, though these sites were not the Trust's properties.

Patients assessed by the liaison psychiatry service did not raise issues about the completion of assessments. Patients did not raise concerns about waiting times to see liaison psychiatry staff, but experienced long waiting times to see acute staff. Patients who received support from the home treatment team told us staff always visited them when they said they would, usually within a specific time scale and did not miss appointments. Some patients had the impression the home treatment team was short staffed, as they sometimes had different staff visited them and visits appeared short.

Staff were suitably experienced, competent, and able to conduct their role. Staff feedback was their roles could be challenging, though the new model aimed to provide greater flexibility to respond to patient needs. The first responder was described as flexible and could cover multiple roles and move between teams. For example, supporting the crisis line, assessment of patients in accident and emergency departments and supporting people in their own homes as part of the home treatment teams. Some geographical areas of the Trust were difficult to recruit to, such as East Cheshire. Vacancy figures did not consistently reflect the impact of vacancies on staff, as they did not include sickness, maternity leave, and other reasons for absence. Gaps in psychology were identified across all the teams in the crisis pathway and the trust had found difficulty in recruiting to these posts. Staff provided mixed feedback about frequency of supervision and appraisal, though staff feedback was they felt supported by their immediate managers.

There were staffing levels and skill mix to make sure people received safe, good quality care that met their needs. With the trust still in the process of embedding new models of care we did not see concerns that impacted assessments being completed, because teams were working flexibly to support the assessment process. Information on staffing was managed through daily resource meetings. The new model included flexibility to move staff across teams, aimed at reducing any unnecessary repetition of assessment processes. However, staff feedback was the impact of ‘self-defined crisis’ meant more people were presenting for assessment, and did not have a mental health condition, which added pressure to the assessment process. Staffing was managed through governance meetings, which identified current vacancy and absence rates. From this meeting the East Cheshire recruitment issue was added to the risk register earlier in 2024. Staffing rosters we requested and assessed as part of the inspection included information for covering staff vacancies, absence, and sickness. When staffing levels appeared below expected levels, this information was not clear and suggested teams could be below stated numbers. However, with staff working flexibly across teams the Trust was managing to assess people and refer to Trust or third sector services.

Staff did not consistently receive the support they need to deliver safe care. This included supervision, appraisal, and support to develop, improve services and where needed, professional revalidation. The overall compliance was rate was 64%.This excluded the two staff groups in management and street triage Chester, which had a rate of 0%. The 3 home treatment teams had an average supervision compliance rate of 62%, liaison psychiatry teams had an average completion rate of 77% and crisis line 73%. The trust appraisal compliance rate reported internally was 71%, and to NHS iEngland as 63%. The 3 home treatment teams had an average compliance rate of 73%, psychiatry liaison teams an average of 60% and crisis line was 80%.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.