Health and Adult Social Care Policy                      22 November 2022

and Scrutiny Committee           


Report of Zoe Campbell, Managing Director, North Yorkshire, York, Selby Care Group, Tees Esk and Wear Valleys Trust

An update regarding Foss Park Hospital CQC inspection


1.    This paper provides an update on the 2 November 2021 report to the Committee regarding the Care Quality Commission (CQC) registration of Foss Park, the 2021 Trust wide inspection of acute wards for adults of working age and psychiatric intensive care units; and subsequent actions taken. It also includes detail of an inspection into Trust wide specialist community mental health services for children and young people which took place 6 - 7 July 2022.


2.    A previous report detailing the development and completion of Foss Park hospital in York, the CQC inspection of inpatient services on site, and the Trust wide inspection of acute wards for adults of working age and psychiatric intensive care units, (including subsequent actions), was presented to the Committee in November 2021. This paper aims to update the Committee on on-going improvement actions and progress and to advise of subsequent CQC inspections in 2022.


3.    Foss Park Hospital was required to be registered with the CQC prior to operational opening. The inspection team were hugely impressed with our design, our knowledge and understanding of how we would use the new facilities to deliver high quality care. As a result, we received formal registration on the day of the inspection.


4.    In January and March 2021 CQC inspected our acute wards for adults of working age and psychiatric intensive care units across the whole Trust. This included:

·        Ebor ward – 18 bed female acute admission ward at Foss Park Hospital, York.

·        Minster ward – 18 bed male acute admission ward at Foss Park Hospital, York


5.    CQC noted that improvements had been made in the time between January and March 2021 however, overall, the Trust received a rating of ‘requires improvement’


6.    The report presented to the Health and Adult Social Care Policy and Scrutiny Committee in November 2021, noted the actions that had been taken following the inspection and up until November 2021.


7.    Since then, the Trust has continued to make improvements and has taken further actions to improve care on acute working age adult wards. We can report to the Committee that:

·        The Trust has continued to invest in anti-ligature work and has spent circa £5m to date on transforming our sites.

·        Personal safes are now in use at Foss Park as the risk of not having somewhere to hold valuables and the possibility of related falls were a greater risk than the ligature risk, especially on organic wards.

·        Staffing skill mix, multidisciplinary teams (MDT) complement, and staffing gender ratios have been reviewed and developed for each ward.

·        We have invested financially in staffing establishments on the wards and have new levels of rostered staffing.

·        MDT roles and responsibilities have been reviewed to enhance clinical leadership and management oversight.

·        The SafeCare staffing module is now fully embedded.

·        Daily ‘report out’ meetings take place on each ward in a handover from night to day shift.

·        Targeted work has been undertaken with agency staff around induction and training and will continue.

·        A new Integrated Performance Report brings together and triangulates data from a range of sources. This is examined monthly by the Executive, the Trust Board, and the North Yorkshire, York and Selby Care Group Board.

·        A new governance structure has been implemented that ensures operations/services benefit from dedicated, multi-disciplinary focus via groups that meet monthly to discuss and agree/monitor actions and improvement relating: risk management, quality assurance and improvement,  people and culture; and use of resources.

·        A Head of Risk has been appointed and a new risk policy and process has been implemented. This is already delivered more robust identification, monitoring and reviewing of risks and mitigating actions.

·        We have invested in ethical international recruitment to fill gaps in staffing. Working with a number of other Trusts, we are currently looking to recruit circa 150 nurses and medics from India and are developing an invest to save business case in international recruitment.

(The above is an example of some of the actions that have been taken and is not an exhaustive list.)

Recent inspections

8.    An inspection of Trust wide specialist community mental health services for children and young people, (including our  Children and Adolescent Mental Health Service (CAMHS) York East and West teams), took place 6 - 7 July 2022.


9.    CQC noted that improvements had been made since the last inspection. However the services overall were rated ‘requires improvement’.


10. CQC reported that:

·        There were still not enough staff in every team to meet the demands of the service. Some teams still had a high number of vacancies and high caseloads.

·        Not all staff were appropriately trained in the mandatory skills required to fulfil their roles.

·        Despite improvements made, some children and young people were still waiting a long time for treatment.

·        The majority of children and young people had safety plans in place but where safety plans hadn’t been created, there wasn’t always justification recorded for this.

·        Staff did not have access to personal alarms at North Durham and not all rooms at Middlesbrough and York were sound proofed.


11. However:

·        The service was achieving its targets of maintaining contact with children and young people on waiting lists.

·        The premises were clean, well maintained and well furnished.

·        We found the trust senior management team had responded promptly to address issues identified at the previous inspection and in the section 29A warning notice. However, this work was ongoing and had not been fully embedded in the service.


12. At the time of writing this report, an action plan is in place and has been submitted to CQC. We can advise the Committee of the following actions which have been undertaken to date:

·        A robust recruitment and retention programme has been developed and is in the process of being implemented.

·        iThrive is now the framework which has been adopted across the CAMHS service. Multi-agency transformation will be informed by this framework.

·        Conversations with partners are taking place around how demand can be addressed as a system (ICS) to understand how patients’ needs are best met (including staffing skill mix and getting it right first time).

·        A caseload deep dive has been undertaken to reduce team’s overall caseload size and to allow for more timely appointments.

·        Conversations have started around a whole system transformation with partner agencies to provide alternative offers to families experiencing mild to moderate mental health need in order to reduce the demands on CAMHS teams.

·        Sound proofing is being fitted in Orca House, York.

(The above is an example of some of the actions that have been taken and is not an exhaustive list.)



13. On 4 July – 2 August 2022 an inspection of forensic inpatient and secure wards was undertaken. The resulting report noted that improvements had been made since last inspection. Overall the Trust was rated  as ‘requires improvement’ for forensic inpatient and secure services. An action plan is in place and has been submitted to CQC.


14. CQC inspected wards for people with a learning disability or autism in 29-30 May 2022, 7-8 June 2022 and 22-23 June 2022. These services were rated’ inadequate’. An action is being developed and is due for submission to CQC on 23 November 2022.


15.  Although we do not deliver forensic inpatients, or have secure wards or wards for people with a learning disability or autism in York; the reports, learning and actions are still disseminated and used to ensure that the York, Yorkshire and Selby Care Group learns from issues, takes on good practice and makes improvements in its own practice. This is managed via weekly Patient Safety & Learning meetings (which also consider complaints and PALs data) and a monthly Fundamental Standards workshop which bring together a range of staff including Managing Directors, Modern Matrons, Therapies staff, Directors of Nursing, Medics and members of the Quality Improvement and People and Culture teams.


16.    The Committee is asked to receive and note this briefing.

Contact Details


Zoe Campbell, Managing Director, Tees Esk & Wear Valleys NHS Foundation Trust