'Not safe, not effective and not well led' - Lancashire's mental health services ordered to improve in damning report

The Care Quality Commission has carried out a review into services run by the Lancashire Care NHS Foundation Trust, which include Guild Lodge in Preston and The Harbour in Blackpool.

The result of the inspection is that the Trust has been given a Requires Improvement rating in three areas - safety, effectiveness and quality of leadership. Two other areas were rated good - caring and responsive - and inspectors noted that individual staff treat patients with care, compassion and dignity.

But the report reveals a catalogue of problems with the service, including;

++ Patients having to sleep in chairs in communal areas because of a lack of facilities

++ Lack of beds meaning that patients detained under the Mental Health Act could not be admitted

++ Staff not able to manage certain patients

++ Staff not monitoring patients after the use of rapid-tranquilisation

++ Broken and boarded up doors in one unit

++ On the child and adolescent ward staff did not always refer to patients in a respectful manner

++ Poor quality food and no access to snacks and drinks for in-patients

++ Low staff compliance with essential training in some core services

++ It was not clear that lessons learned from adverse incidents were effectively shared

One of the most serious issues raised by the report was patients spending too long in crisis support units. Intended as a short-term measure for patients in crisis, the units were frequently being used to hold patients for long periods, because of a lack of available beds elsewhere. The Mental Health Act sets out that patients should only be held in crisis units for 24 hours, but this was “regularly” breached, inspectors found.

Some patients spent several days in the unit which – as they are intended only for temporary use – have no beds, leading the patients sleeping in reclining chairs, sometimes for several days at a time.

The CQC has now issued five requirement notices to the trust, ordering them to improve certain key areas, including eight breaches of legal requirements that were observed by inspectors.

The inspection involved a series of visits by inspectors over a month between January 8 and February 15.

Trust Chief Executive Heather Tierney Moore said: “This is a disappointing outcome for the Trust and this feeling is shared across the organisation. We have dedicated and hard working people at Lancashire Care and this was recognised by the inspection team who saw first hand how caring and responsive our employees are towards patients.

“It is also important that the more positive aspects of the report are not lost. We are really proud of our secure services, Guild Lodge for maintaining the rating of good and of the team at Longridge Hospital who are now also rated good which means our community services overall have a good rating.

“We are clear about what needs to be done to ensure that the people using our services have a good experience and receive high quality services. I personally, along with my colleagues on the Board and senior managers are committed to ensuring that frontline teams are supported to take the learning from this inspection and working together to make the required improvements and build on the positive aspects of it.”

What the inspectors found

The Harbour

Opened in March 2015, the £40m Blackpool-based unit provides in-patient mental health care for people from across Lancashire.

It was a purposed built, state-of-the-art facility and includes four adult mental health wards and two psychiatric intensive care units.

Overall, the trust’s health-based places of safety, which includes the Harbour, the Rigby Suite in Royal Preston Hospital and The Orchard in Lancaster, were rated as requiring improvement.

Inspectors raised concerns about the safety of the services, as staff did not appear to have mandatory training and there was a high use of bank or agency staff to fill gaps in staffing.

They also pointed to breaches of the Mental Health Act by keeping patients in crisis support units far beyond the 23 hours permitted by the act.

However they noted that the staff were caring and compassionate, and involved patients in their treatment plans.

The Cove, Heysham

The Trust’s new facility for child and adolescent mental health care replaced two facilities - the Junction in Lancaster and The Platform in Preston - which have now closed.

The service was rated as requiring improvement, and inspectors noted a litany of concerns including low morale among staff caused by staffing issues.

The unit had broken door panels that had been boarded up and not repaired, giving an unwelcoming atmosphere.

Inspectors also saw what they described as “negative interactions” between staff and patients, where staff did not engage appropriately with patients, and staff did not always follow patients’ care plans.

Patients told inspectors that staff did not know how to control or manage certain patients.

Coroner call for action

In November last year, a coroner demanded action over the case of a patient being transferred from The Harbour who caused a serious crash on the M55 - but was released without being assessed and went on to kill herself.

Tracey Lynch managed to grab the steering wheel after a lone therapist was tasked with driving her across Lancashire, despite her mum warning she would try and jump from the vehicle, her inquest heard.

The 39-year-old was sectioned and taken back to Blackpool’s flagship mental health facility, but placed on a different ward and under the care of a different doctor, and later released without “any form of assessment whatsoever and with only a cursory glance at her previous records”, the hearing was told.

She was transferred to the Oswald House rehab unit in Oswaldtwistle, where she was found hanged days later.

Miss Lynch, from Chorley, died in October 2015 and her inquest held last May.

Her death led to senior coroner Michael Singleton to write to health bosses and demand action is taken to prevent a repeat.

Miss Lynch suffered from a personality disorder and was admitted onto the Stevenson Ward, a secure unit at The Harbour, on Friday, March 17, 2015, after trying to kill herself, Mr Singleton’s report said.

Three months later, it was decided she would be transferred to a rehab unit at Oswald House.

“It was agreed that she would be transferred on September 28 and it was recognised that the transition would be stressful and would lead to an even higher risk of suicide, “ Mr Singleton wrote.

But no discharge meeting was held, and “appropriate escorted transport was not arranged”, he added.

Miss Lynch’s mum, Barbara, told the inquest that “unless she was properly and appropriately escorted in the transport from The Harbour to Oswald House that she would attempt to jump from the motor vehicle”, Mr Singleton added.

He said: “Those concerns were not addressed such that on September 28 when only escorted by the occupational therapist, who was driving the vehicle, Miss Lynch was able to grab the steering wheel and cause a serious accident on the M55 motorway. Despite the fact that risk had previously been identified, there was no attempt to seek to manage that in an appropriate way.”