CQC tells Tees, Esk and Wear Valleys NHS Foundation Trust to make urgent improvements

10 December 2021

The Care Quality Commission (CQC) has told Tees, Esk and Wear Valleys NHS Foundation Trust to make urgent improvements following inspections which took place from June to August.

They carried out an unannounced inspection of forensic inpatient wards due to concerns around unsafe staffing numbers and poor culture within the service. We also looked at how well-led the trust is overall.

In the Harrogate District, they currently operate:

  • CAMHS stands for Children, Adolescent Mental Health Services
  • CMHT stands for Community Mental Health Teams
  • Two wards in the Briary Unit, but now closed

Short notice announced inspections were also carried out at community mental health services for working age adults, crisis services and health-based places of safety, as well as community child and adolescent mental health services (CAMHS). This was due to concerns raised about the safety and quality of these services.

Following this inspection, the crisis services and health-based places of safety had improved and is now rated good, previously it was rated requires improvement.

The overall rating for the trust remains as requires improvement. Community CAMHS also remains rated as requires improvement, and community mental health services for working age adults has gone down from good to requires improvement. The forensic inpatient wards have dropped from good to inadequate.

Brian Cranna, CQC’s head of hospital inspection (mental health and community health services), said:

When we inspected the trust, we found that the leadership team displayed an open and honest culture, however we were concerned regarding the culture within forensic inpatient wards. Due to these concerns we issued the trust with a warning notice, which identified specific areas they must improve in forensic inpatient wards and also improvements required in community child and adolescent mental health services by a set deadline.

During our visit to forensic inpatient wards, we found a poor culture, and staff told us they didn’t feel respected or supported. We found issues with staffing levels which impacted on the quality of care being provided and patients were upset their planned leave didn’t always happen due to this.

Although the trust had commissioned an external review of the culture within the forensic inpatient wards, actions taken to improve it had not been effective. This culture has a negative impact on patient care and must be addressed by the leadership team as a matter of priority.

We were concerned about staffing issues in the community child and adolescent mental health services. People were waiting a long time for autism assessments, and there was a lack of support for people waiting for an appointment. However, we were told the treatment was good quality and staff had provided helpful advice.

The trust has started to address our concerns and know what further improvements are needed to have better oversight of what’s happening across the organisation and improve the culture. We will continue to monitor them and return to inspect on their progress.

In response to the report, trust chief executive Brent Kilmurray said:

We fully accept that there remains much work to be done and we are already taking the steps necessary to address the issues highlighted in this report.

The common factor in most of the issues raised by the CQC is staffing pressures. Easing this pressure is our biggest challenge and we are working extremely hard to resolve this. There is an NHS-wide staff shortage, and the problem is particularly acute in this region. This comes at a time when demand for our services is particularly high and we have invested in recruitment for a range of vacancies and new roles to meet demand.

The pandemic has meant that staff absences due to sickness have been at an all-time high over the last 18 months. It is against this backdrop that our staff are striving to deliver the best possible care.

Our crisis teams – the first port of call for those in urgent need – have performed particularly well to improve their ratings to Good in really difficult circumstances.

That said, we apologise unreservedly for the instances where the high standards we set ourselves have not always been delivered. We are determined to change for the better.

We are taking the culture issues extremely seriously and have put new management arrangements in place to address this, putting our values of respect, compassion and responsibility at the heart of everything we do, all aimed at making this a great place to work.

In the meantime, we will work with the CQC to positively ensure that their requirements are met.

Inspectors found:

  • There were not always enough staff in some services who knew patients well enough to keep them safe. In some services this impacted on the safety and quality of care and meant that staff were not always meeting the needs of patients.
  • There were high waiting times in community mental health services for children and young people. There was a lack of oversight of the waiting list management process and risks to children and young people were not reviewed.
  • Although overall compliance with mandatory training was good, there were some poor compliance. This meant that some staff did not have the required essential skills needed to deliver safe care.
  • Systems and processes to escalate performance and risk issues from ward/team level to board were not effective.
  • Staff did not always report and record incidents appropriately.
  • Patients were not always appropriately safeguarded from abuse and there was no trust-wide policy for safeguarding adults.
  • The trust required continued improvement in its approach to equality and diversity. Staff with disabilities or from a black and minority ethnic background were more likely to experience harassment, bullying or abuse.
  • Investigations into complaints and serious incidents were not always carried out in line with trust policies.


  • The board had approved further workforce investment for inpatient services and there was an ongoing recruitment process in response to staffing challenges.
  • The trust had taken action in response to enforcement action following our inspection of acute and psychiatric intensive care wards. As a result, simplified and introduced more effective systems to assess and manage patient risks within inpatient services.
  • There was good engagement with staff, governors and external partners.
  • The trust had established a new committee of the board (people, culture and diversity committee) and appointed an executive director for people and culture, to embed a more strategic approach to people and culture within the trust.
  • Staff completed annual appraisals, which included discussions on development and career progression.
  • There were robust systems in place in relation to the effective management of medicines and controlled drugs.

The trust says it is already making progress with its ‘Our Journey to Change’ strategy. It is improving leadership, working with patients and carers in developing care packages, recruiting a wider range of different professions and disciplines to strengthen teams, using the latest assistive technology and fundamentally working to embed its new values to influence culture change.


  1. Harrogate Adult Mental Health Services, in my opinion, are not fit for purpose. I have been let down repeatedly by them, which has made my mental health considerably worse. I have no faith, trust or confidence in them whatsoever!

  2. Last Friday I tried to call the Crisis Team 3 times from 8:30pm and never got beyond being on hold. I took an overdose in between the 2nd and third attempt. I then called 999 and asked for an ambulance when I thought a little clearer, it rang for 5 mins and because I couldn’t think straight enough I walked to the hospital, it took me about 45 mins. I was clearly struggling with my heart by this point. Had to explain in front of A&E waiting area what I had done. I was so agitated I couldn’t sit down. I was Triaged after about 40 mins by which time I had tried to check online if the amount I had taken would likely kill me, but I miss calculated what I took and although what I calculated would still be classed as an overdose requiring medical attention etc. I had in fact massively under called it. I know how many tablets I had taken, but in my frame of mind thought I took 50mg per tablet. All it would take from staff would be to check my current prescription to notice the tablets in fact were 150mg each. The triage nurse wanted me to stay, but I tried to reassure him I’d be ok, I just wanted to go home to bed, because I felt too agitated to stay. He asked me to wait whilst he checked with a doctor if I’d be ok to go. He came back and said I needed a heart scan. I insisted I didn’t want to bother anyone and was just going to go home. He asked me to wait a few mins whilst he spoke to a doctor again. However, this time a lady from the mental health liaison team popped out to see me and asked me for my number so Crisis Team could call me the next day, but asked me to try wait for the heart scan. She left, I must have waited 10 mins and couldn’t stand how I was feeling so booked a taxi and went home. My partner knew I’d taken an overdose and still went to bed himself despite me telling him I couldn’t stand how my heart felt. No call from Crisis team over the weekend. Or still for that matter. No call from my CPN. No way to feed back that I can’t get through to Crisis Team when I need them. They are on my crisis plan to call out of hours as the hold my crisis plan on file. I’ve been under the CMHT and crisis team for years and have been 98% disappointed when trying to get through to Crisis Team. How can it change when there’s no way for them to know just how many people can’t get through when the need them? I tried to call PALS today and after 4 calls that all wrong off the hook gave up!

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