North Yorkshire Council

Scrutiny of Health Committee

3^rd October 2025

Tees Esk and Wear Valley Mental Health Foundation Trust – Progress Update 2023-2025

1.0 Purpose of report.

To update and seek questions/areas of clarity from members.

2.0 Content of the report.

The report is split into several sections:

· CQC well led 2023 – outcome of inspection and update on progress against actions.

· Progress and challenges.

· Co-Creation/Lived Experience.

· Community Mental Health Transformation.

· Staff wellbeing initiatives.

2.1 CQC well led 2023 – outcome of inspection and update on progress against actions.

The Trust underwent a ‘core service and well led’ inspection in 2023.

The inspection covered:

· Acute Adult Mental Health Wards and Psychiatric Intensive Care Wards.

· Mental Health Services for Older People Wards.

· Adult Learning Disability Wards/ Day Service.

· Community Adult Learning Disability Teams.

· Community Adult Mental Health Teams.

· Secure In-patient Services (Durham, Tees Valley only).

The Trust overall rating remained as “requires improvement” however 12 CQC domains across the core services inspected had improved. Alongside this, 15 remained the same and 3 decreased.

The report highlighted a number of positives including cultural changes, risk management and governance; and flagged some areas for improvement including compliance with mandatory/statutory training and supervision targets; and waiting times.

[N.B: The overall rating and both the positives and areas for improvement cover the entire Trust not just the North Yorkshire, York Care Group (NYYCG)]

Following the inspection, the Trust was given 38 ‘must do’ actions and 56 ‘should do’ actions. The action plan produced following the inspection included all of the ‘should do’ actions as well as the ‘must do’.

As of September 2025, all of the actions have completed with the exception of 5 (3 ‘must dos’ and 2 ‘should dos’) which are ongoing and within timescales for completion.

The outstanding actions relate to review, development and embedding of policies and staff supervision.

2.2 Progress and challenges.

Key areas of progress in NYY:

· Number of patients in inappropriate out of area placements has dropped from 17 in September 2023 to zero in September 2025.

· Bed occupancy has dropped since 2023. In August 2025 it was at 84.42% which is below target.

· The number of eligible staff with a current appraisal (supervision) has improved substantially and in August 2025 was reported at 87.95% across NYY CG which is above target.

· The number of staff who are recorded as completing mandatory and statutory training has increased substantially since 2023. In August it was reported as 87.77% of courses completed which is above target.

Key challenges in NYY:

· Waiting times remain high for neurodevelopmental assessment in children and young people services. Demand has increased massively over recent years and the commissioned level of capacity is not adequate to meet demand. The commissioner is aware, however there is no additional funding available. Humber North Yorkshire Integrated Care System Mental Health, Learning Disability and Autism Collaborative (HNY ICS MHLDAC), is looking to make improvements to the pathway across Humber North Yorkshire to help alleviate the position.

· There are on-going capacity challenges across services related to both lack of available funding and difficulties recruiting into posts.

· Despite improvement to bed occupancy, we are seeing increasing rates of delayed discharge for people. At the end of August 2025 we reported 18 adults/older people in North Yorkshire who were clinically ready for discharge but could not be discharged due to lack of suitable placements and/or accommodation. We are working closely with local authority colleagues and exploring our own internal processes in order to make improvements, however it is a recognised and challenging issue for all organisations involved.

2.3 Co-Creation/Lived Experience.

Tees Esk and Wear Valleys Trust (TEWV), has demonstrated it’s commitment creation through the recruitment of two Lived Experience Directors who sit on each Care Group Board (CGB); and development of  Co-Creation Boards that sit alongside the CGBs and ensure the voice of service users, patients, carers and staff feeds into Trust decision making and planning at both the service and strategic level.

The CCB in NYYCG was launched in July 2023. To date the CCB has been instrumental in:

· Helping us to get service users and patients working alongside staff in the programme of service peer review visits the CG undertakes as part of its regular quality assurance programme.

· Reviewing, improving and providing assurance to the CGB about the level of engagement and involvement each service speciality undertakes in planning and decision making.

The CCB underwent a full review in February/March 2025 and is currently in the process of a ‘re-set’, the aim of which is to broaden out representation of the Board.

From a Trust wide perspective, there is an Involvement and Engagement (I&E) Team who coordinate and support a range of involvement activities across the Trust and provide support for the people with lived experience who take part in those activities. In April 2024, the Trust’s Quality Assurance Committee endorsed a new co-creation approach to developing Quality Priorities, with each priority co-led by people with lived experience. This ensures that the voice of service users, carers and families is at the heart of quality improvement. The three priorities align with the domains of quality – Patient Experience, Patient Safety, and Clinical Effectiveness and were described within the Trust’s 2024/25 Quality Account.

The Trust also employs Peer Support Workers (PSWs) who work into community services and wards to both enhance our therapeutic offers and to help ensure the voice of people accessing services is heard. The PSWs all have lived experience of secondary mental health and most have come into post following a period of volunteering in our I&E activities. There are 7 PSWs in NYY – 5 in working age adult in-patient services (with 2 more currently being recruited); and 2 in perinatal mental health services. We have also identified funding for 2x Eating Disorder Roles at and 2 roles across Ripon and Harrogate Integrated Team.

2.4 Community Mental Health Transformation (includes North Yorkshire and York).

Highlights include:

· First Contact Mental Health Practitioners (FCMHPs) deployed in 18 of 19 Primary Care Networks (PCNs). Less than 3% of individuals seen by FCMHPs are referred on to secondary care.

· There are two further Community Mental Health hubs in development in the City of York (1 is already open), including a 24/7 Alternative to Crisis National Pilot Site. 

· Further hubs are planned across North Yorkshire over the next 12-18 months, with an expectation that they will all become operational by the Spring of 2026. The procurement process is currently underway for voluntary sector support input into hubs which is being coordinated by North Yorkshire Council.

· Recent investment has been focused on the development of more specialist services in Eating Disorders, Complex Emotional Needs and Early Intervention Services across North Yorkshire (NY).

· There are Complex Emotional Needs Practitioners in post across NY providing expertise, supervision and support for the VCS, Primary Care and the mental health (MH) Hubs.

· New Hybrid Roles created (4 in post) working in Harrogate and Ripon, between Primary Care, Secondary Care and Harrogate and Rural Alliance (HARA).  These roles are designed to more closely align and integrate Primary Care and Secondary Care and to improve patient flow, As hubs emerge across NY these posts will work into those too.

· New Eating Disorder Specialist Practitioners and Consultants now in post and looking to establish Champions across NY and York.

· We have refreshed the communications plan including development of a quarterly stakeholder briefing to inform all partners of updates within the programme locally and regionally.

2.5 Staff wellbeing initiatives.

Strategic Approach & Governance

• Staff Wellbeing Council: We have established a staff-led council to fund and support local health and wellbeing (H&W) initiatives, including distributing over £125, 000 to teams across the Trust.
• Alignment with NHS People Plan: TEWV’s People journey mirrors national priorities—focusing on staff wellbeing, flexible working, psychological safety, and a culture of kindness and respect. We are currently developing and consulting on a H&W strategy and action plan which details our plans for the next 3 years.
• Quarterly Action Planning: Regular review and alignment of wellbeing actions with quarterly reports and the People Plan.  Most H&W offers now are able to provide regular metrics to evidence reach and impact of their service. We continue to progress this and use the NHS Health & Wellbeing Framework to support this.
• H&W Governance Group meets bi-monthly and oversee strategic direction of H&W initiatives.
• Domestic Abuse and Sexual Violence Workstream which is overseen within the People & Culture Directorate (PCD).  The Trust is signed up to Sexual Safety Charter  and work continues to progress with this as per NHSE guidance
• Violence and Aggression  towards staff workstream is ongoing

Health & Wellbeing Programmes

• Performance Habits Programme: Launched in partnership with York University, this real-world evaluation targets  male staff with lower levels of anxiety or depression, with clear signposting for those needing more intensive support.
• Presenteeism Research:  In partnership with York university, the Trust is involved in research to understand presenteeism in the workplace and identify practices which can reduce this.
• Mindfulness & Stress Reduction: Participation in a national Mindful Life-Well at Work study, offering Mindfulness-Based Cognitive Therapy and Stress Reduction Psychoeducation to reduce stress and enhance wellbeing.
• Psychological Services: We have reviewed and reset governance structures for psychological services for staff, with a focus on evidence-based practice, innovation, for psychological safety.

Staff Engagement & Recognition

• Champions for Change & Engagement Champions: We have introduced staff engagement champions via OD team,   increased engagement with our hard to reach groups such as estates/facilities management, health and justice colleagues as part of our Better Health at Work campaigns.  Our network of H&W champions continues to grow – currently at 371.
• Living Our Values Awards: Regular recognition of staff nominated for exemplifying Trust values, with nominations publicised internally and considered for awards.

Supportive Policies & Networks

• Flexible Working & Reasonable Adjustments: Our reasonable adjustments team has been made permanent. Work continues on menopause policy development, and support for flexible working arrangements.
• Staff Networks: Ongoing development and support for staff networks (e.g., EDI, lived experience roles), with guidance and policy under review.
• Leadership & Management Academy: Established to support career development and leadership skills, with a focus on wellbeing and inclusion.
• Refreshed Staff Health, Wellbeing and Attendance procedure :  This take a more proactive and preventative approach, ensuring our support for staff is compassionate, consistent and trauma informed.  This incorporates a stress at work procedure and ensures reasonable adjustments are considered prior to any formal attendance management processes commencing.

Local & Team-Based Initiatives

• Wellbeing Champions: Teams have designated wellbeing champions who organise events, socials, and disseminate wellbeing information. Quarterly H&W champion events.
• Health & Wellbeing Conversations training has commenced as part of our new People Managers programme, staff and managers are encouraged to have H&W conversations outside of usual appraisal and supervision meetings. 

Recognition & Awards

• Better Health at Work Award (Gold): Achieved Gold status for health and wellbeing initiative. Successful in achieving Silver and Gold consecutively, due to be assessed for Continuing Excellence in October 2025.  Campaigns for this year include:  Occupational Health; Harder to Reach Groups; Mens Health; Dignity at Work; Health Checks / MOTs.
• Positive Practice in Mental Health Awards: Reasonable adjustments team highly commended for their work.
• Mindful Employer accreditation

3.0 Conclusion and Recommendations

The Committee is asked to accept the report for information and to ask any questions that arise from the content.

There are no formal recommendations and no implications for consideration.