'Not safe, not effective, not well led': Mental health services told to improve after damning inspection

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

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 – 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.

In November 2017, 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 to jump from the vehicle, her inquest heard.

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

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.”

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 purpose- 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, were rated as requiring improvement.