Inspectors find improvements after NHS trust issued with warning

Inspectors have found improvements following an inspection of services provided by Tees, Esk and Wear Valleys NHS Foundation Trust.
Roseberry Park mental health hospital,Roseberry Park mental health hospital,
Roseberry Park mental health hospital,

The Care Quality Commission (CQC) carried out an unannounced inspection in May of the acute inpatient wards and psychiatric intensive care units (PICU) to check on the progress of improvements the trust were told to make, after being issued with a warning notice in January 2020.

The CQC inspected nine wards across the acute and PICU wards, to look at how the trust were assessing, managing and monitoring risks to patient safety.

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Its team also wanted to ensure the trust were auditing these risks and learning fully from serious incidents.

This inspection looked at how safe and well-led the services were, and sees the service’s rating move overall from inadequate to requires improvement.

The individual ratings for safe and well-led also move from inadequate to requires improvement.

Brian Cranna, CQC’s head of hospital inspection for mental health, said: “At this inspection, we were pleased to see the trust had made progress in the safety and management of these services, improving them for people who rely on staff to keep them safe. But there is still work to be done to make sure these improvements are embedded so they can be sustained in the long term.

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“A lot of the issues we found at our previous inspection related to the environment being unsafe.

"At this inspection, we found leaders had worked to make sure points people could use to harm themselves had been removed or steps taken to reduce the risks around them, and staff we spoke to were clear about this. However staff weren’t always following new policy.

“The trust needs to build on this work and ensure incidents involving people using this service, are recorded in their care files, and just as importantly, are reviewing these more widely and communicating findings to staff to reduce the likelihood of them happening again.

“However, we saw staff who responded quickly to changes and potential risks, and these were shared daily at ward meetings, not just with permanent clinical staff but all staff including housekeepers, and bank and agency staff, so everyone was invested in people’s safety and wellbeing.

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“Leaders know the areas where we expect to see further improvements and we will continue to the monitor this as well returning to check on their progress.”

CQC inspectors found:

:: Although there had been improvements to staff policy, staff were not always following this. For example staff had not locked one window presenting a potential ligature risk despite staff being clear about expectations from them on this.

:: Staff had not updated the written environment risk assessment on Tunstall ward to reflect changes to the environment and staff practice following a significant incident which led to the injury of a patient. The trust addressed this very quickly following the inspection.

:: Leaders at Cross Lane Hospital were using a paper file system for safety briefing reports which did not include all recent reports. This means that there was only one copy available, and in only one location, rather than staff being aware of a more up to date digital version on the intranet which could be accessed by anyone simultaneously. The trust did however address this issue quickly.

:: People’s privacy and dignity wasn’t always considered, especially with the trust having two mixed sex psychiatric intensive care units. Grouping patients together in gender when allocating bedrooms wasn’t always considered.


:: CQC no longer had significant concerns around systemic failures in how senior leaders were managing patient risks in the acute inpatient services.

:: The trust now had better systems in place to comprehensively assess and mitigate patient risk on the acute inpatient wards.

:: The trust now had an effective procedure and process in place to review and learn from serious incidents but they need to make sure this was being undertaken.

:: The trust were making some environmental improvements to improve privacy and dignity and had introduced staff carrying out zonal observations to further improve safety on the mixed sex units.

:: CQC did find some breaches of regulation, and have told the trust where they must improve:

:: Staff must fully record the mitigation for any identified service user risks

:: They must further embed the changes to monitor and mitigate service user risks

:: Continue to mitigate the risks of operating mixed sex accommodation and take all appropriate action to anticipate and prevent sexual safety incidents.

CQC inspected the following nine wards from the acute wards for adults of working age and psychiatric intensive care unit services:

Bilsdale ward – 14 bed male acute admission ward at Roseberry Park, Middlesborough

Bedale ward – 10 bed mixed gender psychiatric intensive care ward at Roseberry Park, Middlesborough

Overdale ward – 18 bed female acute admission ward at Roseberry Park, Middlesborough

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Elm ward – 20 bed female acute admission ward at West Park Hospital, Darlington

Cedar ward – 10 bed mixed gender psychiatric intensive care ward at West Park Hospital, Darlington

Tunstall ward - 20 bed female acute admission ward, Lanchester Road Hospital, Durham,

Esk ward – 11 bed female acute admission ward at Cross Lane Hospital, Scarborough

Ebor ward – 12 bed female acute admission ward at Foss Park Hospital, York

Minster ward – 12 bed male acute admission ward at Foss Park Hospital, York