- SERVICE PROVIDER
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
This is an organisation that runs the health and social care services we inspect
Report from 15 January 2026 assessment
Contents
Ratings - Child and adolescent mental health wards
Our view of the service
- We carried out the assessment for Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust CAMHS inpatient wards on 18,19,20 and 21 August 2025.
- We carried out the assessment in response to concerns raised about the service.
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust was registered with CQC in April 2010 to deliver the regulated activities: Personal Care, Treatment of Disease, Disorder or Injury, Assessment or medical treatment for persons detained under the Mental Health Act 1983 and Diagnostic and Screening procedures. The service had a controlled drugs accountable officer and a Nominated Individual.
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust had 5 CAMHS inpatient wards across 2 locations.
- We visited the following wards as part of our assessment:
Lotus ward – 10 bedded mixed gender general adolescent unit.
Redburn ward - 7 bedded mixed gender general adolescent unit
Stephenson ward – 7 bedded mixed gender medium secure CAMHS ward
The Riding – 7 bedded mixed gender general adolescent unit including 4 psychiatric intensive care beds
Fraser ward 7 bedded low secure mixed gender CAMHS ward for young people who were autistic or had a learning disability.
- We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.
- We carried out 6 short observational framework for inspections (SOFIs) which is an observational tool used to capture the experiences of service users who may not be able to express this verbally for themselves.
- We gathered information from young people using the service and their loved ones, staff and managers, other stakeholders and carried out our own observations. We reviewed a range of documents including care records, policies and procedures. We looked at 33 quality statements.
We rated the service as requires improvement. We found 5 breaches of regulation in relation to safe care and treatment, safeguarding service users from abuse and improper treatment, person-centred care, staffing and good governance.
Staff did not always assess risks to people's health and safety or mitigate them where identified. Environmental safety was not always managed effectively or consistently. For example, comprehensive ligature risk assessments had not been carried out. The use of prone (face down) restraint and mechanical restraint was high and mechanical restraint was not carried out in line with national guidance. Staff had not received all the relevant training to enable them to support the young people they were caring for appropriately. For example, autism training compliance was low. Young people were not always involved in their care and treatment; particularly on Lotus ward where young people were excluded from multi-disciplinary meetings, which were meetings about their care and treatment. Governance systems and audits were not always effective in identifying or addressing areas for improvement.
However, there were sufficient staff to meet the needs of young people in the service.
Staff were caring and respectful towards young people and knew them well. Staff provided a range of activities for the young people which included education which was tailored to young people’s needs. Staff had ensured young people had up to date risk assessments and care plans and most young people who needed them had positive behavioural support plans and sensory assessments. The trust used technology effectively to support staff in caring for the young people at the service. Staff carried out effective handovers after each shift which included a reflection session on the shift in order to identify learning.
We have asked the provider for an action plan in response to the concerns found at this assessment.
People's experience of this service
People’s experience of the service
During our inspection, we spoke with 15 young people and 12 carers. We also reviewed the minutes for 4 young people’s community meetings and reviewed the feedback from surveys the trust sent out to families.
Young people mostly shared positive feedback about staff telling us staff were kind and helpful and that they could speak to them when they needed to. Young people mostly told us they felt safe on the wards. However, some carers shared concerns that young people did not always feel safe when there were higher numbers of agency staff on who did not know young people well.
Young people told us they felt they could share concerns if they needed to, although some young people felt that this did not result in any change. Young people particularly felt they could speak with the peer support worker, who they said got things done. Young people told us they felt included in their care, although most of the young people we spoke to were not aware of what was in their care plan or even if they had a care plan.
Young people told us about the activities they enjoyed including boxing, going to the sports hall, craft and cooking, however some young people said there wasn’t as much going on in the evenings.
Carers provided mixed feedback about the service. Most carers felt the nursing team were very caring and responsive, although some carers felt agency staff did not always interact appropriately or responsively to young people. Some carers had struggled with communication and told us they were not always informed when there had been incidents, although other carers felt well informed.
Carers particularly praised education staff who they said were amazing and the family ambassador, which they said was a really supportive service. Some carers were concerned about the provision of food and told us that food on meal plans were not always available and this could result in young people not receiving the food they required and that food provided was not healthy.
Mental Health Act and Mental Capacity Act Compliance Summary
The provider had relevant up to date Mental Capacity Act and the Mental Health Act policies and staff could access advice on the implementation of the Mental Health Act.
Staff received training in the Mental Capacity Act and the Mental Health Act, although not all staff were compliant with 64% compliance both for Mental Capacity Act and Mental Health Act training. However, staff assessed young people’s capacity on a decision specific basis with regard to significant decisions and recorded best interests’ decisions where this was required.
Staff ensured young people could take Section 17 leave (permission to leave hospital) and explained their rights to young people in a way they could understand and repeated this where necessary. Young people had access to advocacy.