Source · Investigations in the NHS

A system-wide independent investigation into concerns and issues raised relating to the safety and quality of CAMHS provision at West Lane Hospital, Tees, Esk and Wear Valleys NHS Foundation Trust: Published March 2023

North East and Yorkshire Published 01 Mar 2023 Trust Tees, Esk and Wear Valleys NHS Foundation Trust

This is a system-wide independent investigation into concerns and issues raised relating to the safety and quality of CAMHS provision at West Lane Hospital, Tees, Esk and Wear Valleys NHS Foundation Trust. Tees, Esk and Wear Valleys NHS Foundation Trust has also published an assurance statement on their website here.

Acceptance status

Per recommendation

No Response Published

Total recommendations

About this data

Acceptance status tracks whether the trust accepted or responded to each recommendation.

Independent health investigation reports and reviews commissioned by government or NHS England.

About this investigation

Source & metadata

Independent investigation report. Recommendations and any published response are extracted below.

Recommendations

12 total

Recommendation

It is clear from our research that patients and their families (and some staff) were ignored and that their concerns and complaints are now found to be, on the whole, justified. The Trust must seek assurance that complaints, concerns and … Read more

Recommendation

Reporting structures were disconnected between various tiers of governance, and this prevented the ‘drill-down’ required for effective oversight and effective learning. The Trust must ensure rounded reporting arrangements to support proper Board assurance consisting of both hard evidence and soft … Read more

Recommendation

There were gaps in relation to both the commissioning of effective services and in relation to the regulatory oversight in relation to West Lane Hospital. Assurance seeking activity was weak with a lack of sufficient scrutiny of both hard and … Read more

Recommendation

A full assurance review of progress against the recommendations contained within this report must be completed in 6-12 months. This should include all recommendations and all participant bodies.

Recommendation

Formal corporate decision-making processes and outcomes were difficult to trace and evidence. The Trust should seek assurance that there is a ratified minute of key organisational decisions.

Recommendation

Action plans relating to West Lane Hospital were not connected to improvement programmes or risk registers. The Trust should ensure that there is strategic oversight of actions through the Board, Committee or working group where multiple interventions are involved. This … Read more

Recommendation

There were issues with the consistent application of Duty of Candour at the Trust. The Trust should seek assurance that there are now mechanisms in place to assess that the Duty of Candour Policy is effectively implemented. Additionally, where there … Read more

Recommendation

TEWV, CNTW and System Partners need to seek assurance that they have resolved the problems associated with the clinical transitions phase (between services and child to adult). A compound recommendation is required to address this deficit: a) TEWV must provide … Read more

Recommendation

There was a gap between the development and successful implementation of important care initiatives (such as least restrictive practice), plans and evidence-based changes to practice. The Trust must seek assurance that there are implementation plans for new initiatives, policies or … Read more

Recommendation

There was a lack of systematisation in relation to the identification, mitigation and actioning of known risks at a ward, service and corporate level. A compound recommendation is required to address this deficit: a. TEWV must ensure that risk assessments … Read more

Recommendation

The function of Executive team meetings in terms of operational involvement lacked clarity. The Executive team meetings must clearly define and record actions which they are directly responsible for, or, where actions have been delegated. The ET should recognise that … Read more

Recommendation

Safeguarding between mental health providers and system partnerships was insufficient to protect young people in West Lane Hospital. Despite the availability of Working Together Guidance, responsibilities and obligations internally and externally between agencies (providers and system colleagues) were confused, interpreted … Read more Safeguarding between mental health providers and system partnerships was insufficient to protect young people in West Lane Hospital. Despite the availability of Working Together Guidance, responsibilities and obligations internally and externally between agencies (providers and system colleagues) were confused, interpreted differently by individuals and consequently gaps developed. A compound recommendation is required to address this deficit: a. NHS England Specialised Commissioning, the North East & North Cumbria ICB and provider collaborative and the South Tees Safeguarding Children Partnership Board and LADO should now all reflect upon matters raised within this report and determine whether further internal review is required to ensure proper learning occurs within each respective agency. All relevant Safeguarding Children’s partnerships need to ensure that there are sufficient mechanisms in place to prevent a recurrence of the same. b. The North East & North Cumbria ICB and provider collaboratives should obtain assurance that provider organisations have sound systems and processes to safeguard young people in mental health facilities, and these provide regular robust assurance to NHS England Specialised Commissioning of effective working. c. Middlesbrough Council and Health providers/ key partners must ensure that there is clarity about the roles and responsibilities of each agency in the planning and delivery of care to young people in Tier 4 CAMHS provision to ensure that support is holistic and meets the educational; social; physical health and emotional needs of children and young people as well as their mental health needs. d. Local Authorities and Health providers must provide appropriate challenge where there are concerns about unsafe discharge arrangements from Tier 4 inpatient care, including appropriate escalation up to chief officers where concerns for children’s safety are high. e. Durham County Council must ensure that responses to referrals are completed within expected time frames, and subsequent assessments always incorporate the views of the family and young person. f. North East and North Cumbria Integrated Care Board and the Provider Collaborative must consider the impact and risks on Tier 4 CAMHS if a local Safeguarding Board is found to be weak or inadequate, or a local provider is found to have a major staffing issue. g. Where Safeguarding concerns are raised about a child, these must include a formal consideration of other vulnerable family members for the lifespan of care. h. Middlesbrough Council must respond formally to serious concerns raised about the care and treatment of a young person under their care and explore concerns with the family and the young person. Show less